We inspected Avalon Nursing Home on the 17 and 18 December 2018. This was an unannounced inspection.

Avalon Nursing Home 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 Nursing Home provides nursing and personal care for up to 38 older people, some of whom were living with a dementia type illness. There were 27 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care needs which included stroke and diabetes. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

Avalon Nursing Home is owned by Elderly Care Home Limited and is situated in Hampden Park in Eastbourne, East Sussex. Accommodation for people is provided over two floors with communal areas and a garden.

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 and associated regulations about how the service is run. Avalon Nursing Home had two registered managers at this time who work together to manage the service. The senior registered manager visits three days a week and the junior registered manager is in day to day charge.

We inspected Avalon Nursing Home in August 2015 where the overall rating for this service was Inadequate. We looked to see if improvements had been made in May 2016 and found that improvements had been made and breaches in regulation had been met. However, the improvements had not been fully embedded in practice and the service was rated as Requires Improvement. Due to a high number of concerns raised we brought our scheduled inspection to November 2016. We found people's safety was being compromised in a number of areas and the home was rated as Inadequate and was once again placed into special measures. We inspected again in July 2017 we found that improvements had been made across all areas of the service. But the breaches of Regulations 9, 11, 12, 17 and 18 were not fully met. We took appropriate enforcement action at that time. The provider had continued to provide CQC with monthly audits of the service delivery.

This inspection found that improvements had continued and that the rating for Safe and Effective improved to Good, Caring had remained Good and Responsive and Well led had remained as Requires Improvement. The breaches of regulation whilst met were not fully embedded into everyday care delivery and further time is needed to ensure that improvements are pro-actively sustained. The overall rating of this inspection is Requires Improvement.

There was continued commitment from the management team and staff to consistently strive for improvement. Areas identified as needing to improve at this inspection were immediately acted on and details of the actions taken were sent to CQC. This demonstrated that the management were responsive and wanted to improve their service.

The quality assurance system, audits and checks had not identified the shortfalls we found. Care plans did not consistently contain the detailed information staff needed to support people to meet their individual needs and care documentation was not consistently and accurately recorded. However, management had a good oversight of what was required to ensure the service continued to improve and meet the regulations. Staff told us they felt supported by the registered managers, they could talk to either of them and raise issues at any time. They felt listened to and knew any concerns would be taken seriously and acted on.

People were relaxed and comfortable with staff.

We inspected Avalon Nursing Home on the 17 and 18 July 2017. This was an unannounced inspection. Avalon Nursing Home provides nursing and personal care for up to 38 older people, some of whom are living with a dementia type illness. There were 27 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care needs which included stroke and diabetes. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

Avalon Nursing Home is owned by Elderly Care Home Limited and is situated in Hampden Park in Eastbourne, East Sussex. Accommodation for people is provided over two floors with communal areas and a garden. There were two lounges; one was called the nursing lounge and the other the Dennis Cullen wing.

At the time of this inspection there was no registered manager in post. An appointed manager was in post who was also a registered manager for another service owned by the provider. They had submitted their application to register with the CQC. 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 and associated regulations about how the service is run. After the inspection the manager became the registered manager following an interview with CQC.

At a comprehensive inspection in August 2015 the overall rating for this service was Inadequate. At this time we placed the service into special measures. Seven breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. The provider sent us an action plan and told us they would address these issues by February 2016.

During our inspection in May 2016, we looked to see if improvements had been made. The inspection found that improvements had been made and breaches in regulation had been met. However, the improvements had not been fully embedded in practice and they needed further time to be fully established in to everyday care delivery.

Due to a high number of concerns raised about the safety of people, care delivery, deployment of staff and staffing levels we brought forward a scheduled inspection to November 2016. We found people's safety was being compromised in a number of areas and the home was rated as Inadequate and was once again placed into special measures.

This inspection found that improvements had been made across all areas of the service. However, these improvements were not, as yet, all fully embedded in practice and need further time to be fully established in to everyday care delivery. The breaches of Regulations 9, 11, 12, 17 and 18 were not fully met.

There was a commitment from the manager and staff to continue with the improvements that had already taken place. The manager, provider and director acknowledged that this would take some time. They told us they wanted improvements to be fully embedded and would take their time to ensure this was done properly. Staff were now aware of their roles and responsibilities and had an understanding of the vision and direction of the home.

The quality assurance system, audits and checks had not identified all the shortfalls we found. Care plans did not consistently contain the detailed information staff needed to support people to meet their individual needs. However, the manager had a good oversight of what was required to ensure the service continued to improve and meet the regulations. Staff told us they felt supported by the manager, they could talk to her and raise issues at any time. They felt listened to and knew any concerns would be taken seriously and acted on.

Risks were not consistently managed safely. Systems were not in place to ensure people’s pressure relieving mattresses were set correctly and people were plac

We inspected Avalon Nursing Home on the 29 and 30 November 2016. This was an unannounced inspection

Avalon Nursing Home provides nursing and personal care for up to 38 older people, some of whom are living with a dementia type illness. There were 28 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care needs which included stroke, diabetes and Parkinson’s disease. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

Avalon Nursing Home is owned by Elderly Care Home Limited and is situated in Hampden Park in Eastbourne, East Sussex. Accommodation for people is provided over two floors with communal areas and a garden.

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 and associated regulations about how the service is run.

At a comprehensive inspection in August 2015 the overall rating for this service was Inadequate. At this time we placed the service into special measures. Seven breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. We found there were not enough staff deployed to meet people’s needs. Staff had not received appropriate support or supervision. Staff did not understand their individual responsibilities in reporting safeguarding concerns. Where people did not have the capacity to consent, the registered person had not acted in accordance with legal requirements. The registered person had failed to notify the Care Quality Commission about any incidents that affected people who used the service. A notification is information about important events which the provider is required to tell us about by law. The premises were not always hygienic or safe to use. Care was task based rather than responsive to individual needs. People were not consistently treated with dignity and respect. The provider had not ensured that service users were protected from unsafe care and treatment by the quality assurance systems in place. We issued warning notices for these breaches. The provider sent us an action plan and told us they would address these issues by February 2016.

During our inspection in May 2016, we looked to see if improvements had been made. The inspection found that improvements had been made and breaches in regulation had been met. However the improvements were not fully embedded in practice and they need further time to be fully established in to everyday care delivery.

Due to a high number of concerns raised about the safety of people, care delivery, deployment of staff and staffing levels we brought forward the scheduled inspection to the 29 and 30 November 2016, so we could ensure that people were receiving safe care from sufficient numbers of suitably qualified staff.

At this inspection, people’s safety was being compromised in a number of areas. The provider had been unable to sustain the improvement made at the last inspection. Care plans did not reflect people’s assessed level of care needs and care delivery was not person specific or holistic. We found that people with specific health problems such as pressure ulcers and wounds were not all up to date and did not have sufficient guidance in place for staff to deliver safe treatment or prevent a re-occurrence. The lack of appropriate deployment and suitably qualified and experienced staff impacted on the care delivery and staff were under pressure to deliver care in a timely fashion. Shortcuts in care delivery were identified. We also found the provider was not meeting the requirements of the Mental Capacity Act (MCA) 2005. Mental capacity assessments were not completed in line with legal requir

At our previous inspection of Avalon Nursing Home on the 3, 4 and 12 August 2015 we found breaches in regulation. We found there were not enough staff deployed to meet people’s needs. Staff had not received appropriate support or supervision. Staff did not understand their individual responsibilities in reporting safeguarding concerns. Where people did not have the capacity to consent, the registered person had not acted in accordance with legal requirements. The registered person had failed to notify the Care Quality Commission about any incidents that affected people who used the service. A notification is information about important events which the provider is required to tell us about by law.

We also found breaches in regulation where care and treatment had not been provided in a safe way. The premises were not always hygienic or safe to use. Care was task based rather than responsive to individual needs. People were not consistently treated with dignity and respect. The provider had not ensured that service users were protected from unsafe care and treatment by the quality assurance systems in place. We issued warning notices for these breaches. A warning notice includes a timescale by when improvements must be achieved. If a registered person has not made the necessary improvements within the timescale, we will consider further enforcement action. The provider sent us an action plan and told us they would address these issues by February 2016.

We undertook an inspection on 9 and 12 May 2016 to follow up on whether the required actions had been taken to address the previous breaches identified. We found significant improvements had been made. However, these improvements were not, as yet, fully embedded in practice and need further time to be fully established in to everyday care delivery.

Avalon Nursing Home provides nursing and personal care for up to 38 older people, some of whom are living with a dementia type illness. There were 28 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care

needs which included stroke, diabetes and Parkinson’s disease. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

At the time of the inspection there was no registered manager at the home. There was a manager in post who had submitted an application to register with the Care Quality Commission (CQC) and were registered shortly after the inspection. 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.

There was a system in place to assess the quality of the service provided. The provider and manager were aware of the shortfalls we identified and were working to ensure improvements were made and embedded into everyday practice.

People were supported by staff who knew them well, were kind and caring and enjoyed looking after people. There was an emphasis on providing good person-centred care and getting to know and understand people as individuals. However, care plans did not always provide staff with the information they required to support people and did not always reflect the care people received. We observed staff had built a good rapport with people and responded to staff with smiles and affection.

There were a range of environmental and individual risk assessments in place to ensure people were looked after safely. However, information from risk assessments was not always used to update people’s care plans.

Mealtimes were an enjoyable and social occasion where people received the appropriate care and support they required.

Staff understood the principles of consent and the Mental Capacity Act (200

We carried out this inspection to follow up on a compliance action set at the last inspection.

During the inspection we looked at people's care records and associated documentation. We found that people had been protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records had been maintained.

Avalon Nursing Home provides nursing care for older people. Some people using the service had complex needs, which meant they were not able to tell us their experiences. Those who could told us that they were happy with the level of care provided. We were told "my family visit me every week, I like my room it is nice and warm" and "I get up when I feel like, it depends what time I wake up." One person we spoke with told us that the food is "fine, you get a good choice."

The registered manager at Avalon works as the matron in the home, and is referred to as the matron throughout this report.

During our inspection we found that people had been respected and involved in decisions about their care and treatment. People were receiving appropriate care, treatment and support to meet their needs.

Meal choices were being offered which took into account peoples likes, dislikes, specific dietary needs, cultural and religious requirements. People had been referred to outside agencies appropriately, and care plans updated and reviewed.

A complaints policy and procedure was in place. A copy of the complaints procedure was displayed in the main entrance area. People we spoke with who lived in the home told us they would be happy to raise any concerns if they needed to.

Accurate records had not been maintained. We saw that some documentation did not include accurate, appropriate information in relation to the care and treatment provided to some people who lived in the home.

We used a number of different methods to help us understand the experiences of people who used the service. Some people had complex needs, which meant they were not able to tell us their experiences. Those who were able to told us they were happy.

During our inspection we found that care and treatment was being provided to meet people’s needs and personal preferences. People’s views and experiences had been taken into account when planning care. The provider had effective measures in place to regularly assess and monitor the quality of service provided.

Due to people’s complex needs, many people were not able to tell us about their experiences. We used a number of different methods such as observation of care and reviewing of records to help us understand the experiences of people using the service.

People we were able to speak with who lived in the service told us they liked living at Avalon. We were told “nice staff, nice food” and “I have a nice room here, very comfy”.

We also spoke with relatives and visitors. One visitor told us “I have never had any issues, there is always someone senior around if you need to speak to them, we are very happy with the care here”.

Avalon Nursing Home provides nursing and personal care for up to 38 older people, some of whom are living with a dementia type illness. There were 37 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care needs which included stroke, diabetes and Parkinson’s disease. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

Accommodation was provided over two floors with two passenger lifts that provide level access to all parts of the home.

Our records showed there was a registered manager at the home, however this person was no longer in post at Avalon Nursing Home but worked at another home which belonged to the provider. They were in the process of deregistering as the registered manager with the Care Quality Commission (CQC) for this service. A registered manager is a person who has registered with the CQC 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 time of our inspection there was an acting manager in post. During the inspection the provider told us they were in the process of recruiting a new manager who would become the registered manager.

This was an unannounced inspection which meant the provider and staff did not know we were coming. It took place on 3, 4 and 12 August 2015.

People’s safety had been compromised in a number of areas. There were not enough staff on duty to safely meet people’s needs. People’s needs had not been taken into account when determining staffing levels.

Staff told us they understood different types of abuse. They told us what actions they would take if they believed someone was at risk. However, concerns raised were not always appropriately reported to the local safeguarding authority.

Medicines were stored safely and people received their medicines when they needed them.

Individual risk assessments to maintain people’s health, safety and well-being were not in place for everyone and therefore placed people at risk.

Staff knew people well and were able to tell us about the care they required. However, care plans lacked details of how to manage and provide person specific care for their individual needs.

There was no information about how people decided where they would like to spend their day. There were a range of activities in place. However, staff did not use their knowledge of people to engage them in more meaningful activities throughout the day.

The premises were not always safe or hygienic. Cleaning products that should be locked away had been stored in an area that was accessible to people. Doors that should have been locked were open, this included a boiler room with hot water pipes. Communal bathrooms were used as storage areas and we saw linen and pillows stored next to a toilet.

Staff did not always follow the principles of the Mental Capacity Act 2005. Mental capacity assessments did include information about how decisions were made or what decisions people could make for themselves.

Mealtimes were disorganised and did not provide a pleasurable eating experience for people. Although people did receive support it was task based and not individualised. People told us staff were generally kind and caring however we observed occasions where people were not treated with respect and their dignity was not maintained.

Staff told us about the training they received however we were unable to view records to confirm what training staff had received. Supervision was not embedded into practice or valued amongst staff. Therefore not all staff received ongoing professional development through regular supervisions.

The provider had systems in place for monitoring the management and quality of the home but these were not always effective.

A complaints policy was in place. People and relatives were happy to discuss any concerns with staff. However, the provider was unable to find any records of complaints.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.<Summary here>