About the service:

Avalon EMI Care Home is a residential care home that was providing personal and nursing care to 18 people aged 65 and over at the time of the inspection.

People’s experience of using this service:

Following the last inspection, we met with the provider to confirm what they would do and by when to improve the key questions Effective and Well Led to at least good. We asked the provider to take action to make improvements to monitoring staff training and to mental capacity assessments, and this action has now been completed.

People told us that they felt safe living at the service. Care records provided detailed information around people's individual risks in order for staff to keep them safe from avoidable harm. Person centred care was delivered, giving people choice over their daily routines in line with their preferences.

Staffing levels were appropriately managed and people received care from consistent, regular staff. Enough staff were employed each day to meet people's needs and keep them safe. Our observations during the inspection showed that care was provided in a safe manner and staff were available when people required support.

Recruitment processes were robust. The necessary pre-employment checks were completed, and people received care from staff who were suitable to work in adult social care environments.

Processes and systems were in place to ensure people received their medicines when they needed them, from trained and competent staff.

People's overall health and well-being was effectively assessed and managed. Referrals were made to external healthcare professionals accordingly.

People made positive comments about the food they received. Menus offered a variety of home-made and fresh meals each day. People received support to eat their meals when they needed it.

People were supported in a kind, caring and compassionate manner. Staff were familiar with the support needs of the people they were supporting. Staff engaged in meaningful conversations with people to provide stimulation and reassurance.

The registered provider had a complaints policy in place. No complaints had been made since the last inspection.

People were encouraged to participate in a programme of activities.

The home was clean and hygienic. Health and safety measures were in place to ensure people lived in a safe, well-maintained environment.

More information is in Detailed Findings below

Rating at last inspection: Requires Improvement (Report published October 2018). At this inspection we found the overall rating had improved.

Why we inspected: We were due to inspect the service in October 2019, based on the rating of the previous inspection. However, the inspection was brought forward due to information of concern we received regarding low staffing numbers.

Follow up: No concerns were raised within this inspection. We will therefore aim to re-inspect this service within 30 months. We will continue to monitor the service through the information we receive. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The inspection took place on 25 and 26 September 2018 and was unannounced on the first day.

Avalon is a care home that provides personal care and support for up to 26 people living with dementia. There were 22 people in the home during our inspection.

Avalon is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Avalon accommodates people in one adapted building. The home is set in a residential area of Southport, close to the town centre. A lift provides access to all floors and there are two separate communal areas. There is a well-kept garden area to the front and side of the building.

Avalon was previously inspected in December 2017. During the inspection we found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that when people were unable to consent, the service had not always followed the principles of the Mental Capacity Act 2005. This was because an assessment of the person’s mental capacity was not always decision specific.

Following the last inspection on 13 December 2017, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Is the service Effective, to at least good.

The home has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 13 December 2017, we asked the provider to take action to make improvements to the completion of mental capacity assessments. At this inspection we found the service continued to require improvement in the understanding and use of the Mental Capacity Act 2005. We found issues in the way the service applied principles of the MCA. Completed assessments were not ‘decision specific’. Managers still showed a lack of understanding of the Mental Capacity Act. This was a continued breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Quality assurance audits were completed by the manager and deputy manager which included, medication and health and safety. However, issues found during the inspection had not been identified as part of this process.

This is the second, consecutive time the service has been rated Requires Improvement.

You can see what action we told the provider to take at the back of the full version of the report.

Everyone who lived in the home said they felt safe. There were robust measures in place to ensure people were safe. Risk assessments were in place for areas such as pressure care, falls and mobility, and nutrition and hydration.

Safeguarding systems processes and practices helped staff to understand how to protect people from abuse, neglect, harassment and breaches of their dignity and respect.

There were sufficient staff on duty to meet people's needs. Staff rotas showed a consistent number of staff were on duty each day. People told us call bells were answered within a reasonable time. This helped to evidence there were enough staff to support people safely.

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults.

Medicines were managed safely and people received their medicines as prescribed. Staff had been trained to administer medicines to ensure their competencies and keep errors to a minimum.

The home was very clean and there were no odours. Personal protective equipment (PPE) such as aprons and gloves were available and used when supporting people with personal care and administering medication.

The home was well maintained an

Avalon is a care home that provides personal care and support for up to twenty six people who are living with dementia. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The providers [owners] are Mr K Jones and Mr R Brown.

The service was last inspected in October 2015 and was rated ‘Good’ at that time. This is the first time the service has been rated ‘Requires Improvement’.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person’s mental capacity was made. When people were unable to consent, the principles of the Mental Capacity Act 2005 were not always followed in that an assessment of the person’s mental capacity was not always made with reference to specific key decisions.

You can see what action we told the provider to take at the back of the full version of this report.

We found the design and adaptation of the premises could be further improved with respect meeting the needs of people living with dementia.

We made a recommendation regarding this.

The manager and senior managers for the provider were able to evidence a range of quality assurance processes and audits carried out at the home. We found quality assurance systems needed further developing in line with providing further good practice for people living with dementia.

We made a recommendation regarding this.

We found medicines were being safely managed. Key staff were responsible for monitoring and administering medicines. The administration records for some medicines such as prescribed ‘thickeners’ for drinks (for people with swallowing difficulties) could be further improved.

We looked at how staff were recruited and the processes to ensure staff were suitable to work at Avalon EMI care Home. We saw required checks had been made to help ensure staff employed were ‘fit’ to work with vulnerable people. We found there were sufficient staff on duty to meet people’s care needs.

People’s clinical care was assessed for any risks and organised so plans were put in place to maximise people’s independence whilst help ensure people’s safety.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. Training records confirmed staff had undertaken safeguarding training in-house. Not all of the staff we spoke with were clear about the wider issues around ‘safeguarding’ people and this was feedback to the registered manager to inform future training.

Arrangements were in place for checking the environment to ensure it was safe. Health and safety checks were completed on a regular basis so hazards could be identified. Planned development / maintenance was assessed and planned well so that people were living in a comfortable and safe environment. The home was clean and there were systems in place to manage the control of infection.

Staff said they were supported through induction, appraisal and the home’s training programme. People we spoke with and their relatives felt staff had the skills and approach needed to ensure people were receiving the right care.

We found the home supported people very well to provide effective outcomes for their health and wellbeing. We saw there was regular and effective referral and liaison with health care professionals when needed to support people. Feedback f

Our inspection was carried out unannounced. The inspection helped answer our five questions:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People who lived at the home and their relatives and visitors told us they were treated with respect and dignity by the staff. They told us care was good and if they had any medical issues that needed monitoring, or to be followed up, this was arranged. People told us they felt safe and well cared for.

Systems were in place to make sure that the home was maintained safely with respect to health and safety issues. We saw that gas, fire, water and electrical safety were continually monitored.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. We were told about one application that had been made. This showed that the service understood the process involved. The home had also introduced an assessment for measuring people’s mental capacity in terms of individual decisions that might need to be made. However, we found that these assessments were not very clear. For example one part of the assessment for a person seemed to show the person had capacity to make decisions but further on it was recorded that staff seemed to be acting in the person’s best interest and making decisions for them. We discussed this and the manager said she would review the assessment form to make it clearer.

Is the service effective?

People’s health and care needs were assessed. Specialist dietary needs had been identified where required. From reviewing the care of people we saw that the care being carried out reflected their current needs.

People told us that staff asked them about their care and they felt involved.

One relative told us, ‘’I can’t fault the place – it’s excellent and I’ve just completed one of their surveys to tell them.’’ another said, ‘’The care is very personalised, very person centred.’’ When we asked what they meant by this we were told that staff spent time thinking about each person separately and what was best for them as people.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, “The staff are very good and the food is good. I’m fine.’’, ‘’There’s lots to do. They [staff] put films on regularly – some good ones too’’, “I’ve been settled since I’ve been here, the staff have really sorted me out’’ and ‘’We do different sorts of activities. It’s very good. We get to choose whether we join in.’’

People said staff did everything needed to support them with their day to day living.

We observed staff continually working to support people with all aspects of care. We observed staff communicating and interacting well whilst supporting people. We saw one example where care was not carried out as effectively as it could have been and we fed this back to the manager.

People’s preferences and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

We saw that people were supported to complete a range of daily activities and this included support with social activities. Social activities were organised on a daily basis and we saw examples of people being actively engaged and involved throughout the day of our inspection.

People were supported as their care needs changed. This was particularly evident with two people who had changing needs concerning support with their diet.

We found that any issues identified by the home’s systems of monitoring were addressed and the improvements made. For example the way food and drinks were organised in the morning had recently been reviewed. The home’s manager had a range of easily accessible information to help monitor and plan any changes needed to improve the service.

Is the service well-led?

The service had a quality assurance system. This included both internal and external audits [checks]. The system of audits helped support the manager to run the home effectively. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes that were in place. This helped to ensure that people received a good quality service at all times.

We saw some improvements from our inspection carried out in January 2013.

People who were able to give an opinion told us they were happy with the care and support they received. Their comments included, “I know I can see my doctor when I need to and the staff will organise this.” We spoke with a relative of a person living at Avalon who told us that their relative had settled well and was being well cared for. They commented, ‘’ [Person] was previously isolated but she is happy here and talks to the other residents.’’ People felt their privacy and dignity were respected.

Further improvements included monitoring infection control and people were protected from the risk of infection because appropriate guidance had been followed.

We also saw that the service have recruited extra staff and there were enough qualified, skilled and experienced staff to meet people’s needs.

We found that people were listened to so that any concerns could be addressed. The manager said she would ensure that the current complaints process was better advertised in the home.

Before people received any care or treatment they were asked for their consent and staff acted in accordance with their wishes. Staff were seen to be actively asking people’s consent and offering choices when appropriate.

We received positive comments from people we spoke with about the staff. Comments included: ‘’Staff are approachable and they explain everything to me.’’ We spoke with health care professionals visiting the home who said that staff liaised well and appeared knowledgeable regarding the people living at Avalon.

We identified a period during the morning where there were not enough qualified, skilled and experienced staff to meet people’s needs. This compromised the care of vulnerable people and exposed them to unnecessary risk.

People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

The laundry area was not being effectively monitored and there were some practices which increased the likelihood of cross infection.

We visited Avalon and we spoke with some of the people who lived there. Overall it was difficult to ascertain their views and informed opinion due to the progressive state of their dementia. We were however informed by a person who lived at the home that they were happy with the care and support they were receiving. They also said they were satisified with their room and standard of furnishings.

We talked to one resident and one visiting relative and sat in the main lounge for about an hour with some of the other residents. We were told that staff are helpful and respond to calls for assistance when needed. Residents appeared to have a relaxed relationship with their carers.

This was an unannounced inspection which took place over two days on 21 & 22 October 2015. The service was last inspected in June 2014 and was meeting standards at that time.

Avalon EMI Care Home provides personal care and support for up to 20 people who have dementia. The home is set in a residential area of Southport, close to the town centre. A lift provides access to all floors and there are two separate communal areas.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

When we spoke with people living at Avalon they told us they were settled and felt safe at home. All of the people we spoke with commented on consistently good standards of care.

To support the 19 people accommodated at the home during our inspection there was normally a minimum of six care staff on days as well as the registered manager. We saw from the duty rota that this staff ratio was consistently in place to provide safe care.

We looked at how staff were recruited and the processes to ensure staff were suitable to work with vulnerable people. We saw checks had been made so that staff employed were ‘fit’ to work with vulnerable people.

We found that staff were good at managing risks so that people could be as independent as possible. We spoke with health care professionals who visited and supported people in the home. They felt that staff managed people’s care needs well and this included ensuring their safety.

When asked about medicines, people said they were supported well. We saw there were good systems in place to monitor medication safety and that staff were trained to help ensure their competency so that people received their medicines safely.

The staff we spoke with clearly described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. Training records confirmed staff had undertaken safeguarding training. All of the staff we spoke with were clear about the need to report any concerns they had.

Arrangements were in place for checking the environment to ensure it was safe. For example, health and safety audits were completed on a regular basis where obvious hazards were identified. The home was undergoing planned development at the time of the inspection and we saw this had been assessed and planned with a high degree of attention to detail and health and safety issues so that the work was being carried out safely.

We observed staff provide support and the interactions we saw showed how staff communicated and supported people as individuals. Staff were able to explain in detail each person’s care needs and how they communicated these needs. People we spoke with, relatives and health care professionals were aware that staff had the skills and approach needed to ensure people were receiving the right care. The comments we received evidenced staff going the ‘extra mile’ to ensure people received effective support.

We saw that the home was working within the legal framework of the Mental Capacity Act (2005) [MCA]. This is legislation to protect and empower people who may not be able to make their own decisions. We had some discussion into how this could be further developed with respect to good practice.

There were two people who were being supported on Deprivation of Liberty [DoLS] authorisations. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. We found these authorisations effective and they were being monitored by the manager of the home.

People told us the meals were good and well presented. We observed and spoke with people enjoying breakfast and lunch. We were told that breakfast was flexible and there was always choice available with all meals.

We asked people if they were treated with dignity, respect, kindness and compassion. People said their privacy was respected and they were well cared for. All of the people we spoke with including visitors and professionals commented on the caring nature and philosophy in the home. We were told this permeated all of the interactions in the home. We made observations at times throughout the inspection. The interactive skills displayed by the staff when engaged with people were extremely supportive and showed a highly personalised approach to help ensure people’s wellbeing.

We found that care plans and records included people’s preferences and reflected their identified needs from admission and during their stay. There was evidence that care plans had been discussed with people so they felt involved in their care. People we spoke with all felt involved and up to date with their plan of care.

Social activities were organised. These were both community activities and also some individualised activities and outings. There was strong accent on this and there was staff members who organised and supported activities.

Well-developed processes were in place to seek the views of people living at the home and their families. The manager was able to evidence a series of quality assurance processes and audits carried out. These were comprehensive and helped ensure standards of care were maintained consistently as well as providing feedback for ongoing development of the service.