We carried out an inspection of Avandale Lodge on the 22nd and 23rd of October 2018. The first day was unannounced and the second day announced.

The service had a registered manager who was registered with us in January 2018. 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. The manager was present during the days of our visit.

Avandale Lodge 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. Avandale Lodge is registered to accommodate 48 people living with dementia. At the time of our visit, 39 people were living there.

During the last inspection on 7th, 9th and 12th March 2018 we found that there were a number of improvements needed in relation to safe care and treatment, staffing and good governance. These were breaches of Regulations 12, 13, 17 and18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated as requires improvement overall and inadequate in the Safe domain.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Caring, Responsive and Well Led to at least good. The provider sent us an action plan that specified how would they would meet the requirements of the identified breaches.

During this inspection we found that whilst some of the required improvements had been made, other required improvements had not been met and that other areas of improvement had been identified.

Improvements had been made to the management and administration of medicines. We found that medicines were managed safely in accordance with good practice guidelines. Staff had received training and had their competency assessed.

Improvements had been made with regards to the submission of notifications to the CQC where specific incidents had occurred that adversely affected the wellbeing of people. This is a legal duty which the provider is required to meet.

Some improvements had been made to ensure that agency staff had more information about the needs of people who used the service. This ensured that agency staff were better placed to meet the needs of people.

This visit found that some improvements had not been made and as a result breaches had been repeated. These related to care and treatment with the registered manager not reporting low level safeguarding concerns to the local authority, not taking steps to investigate events where people who used the service sustained unexplained injuries and not using the registered provider’s systems fully to report incidents that had occurred. Another related to the governance of the service whereby shortcomings in the quality of the service had not been identified during audit undertaken. Further shortcomings were identified in respect of managerial support for staff when the registered manager had been absent.

The use of agency staff had decreased but all registered nurses on nights were still sourced by an agency.

We have raised a recommendation in respect of the premises being supportive for those who live with dementia.

Despite shortcomings in the following of local authority procedures, staff were aware of the types of abuse that could occur and were familiar with the reporting procedure.

Staff recruitment was robust and included appropriate checks on new members of staff.

The premises were clean and hygienic. Assessments were in place to minimise the spread of infection.

Risk assessments relating to malnutrition and the development of pressure ulcers

This inspection was unannounced and took place on 7, 9 and 12 of March 2018.

The last inspection of the service was carried out on 6 & 7 July 2017 and published on 22 August 2017. At that time the service was rated as good.

Avandale Lodge 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.

Avandale Lodge Nursing Home is purpose built and provides care for up to 48 people who require support with nursing and personal care. The service specialises in supporting older people and at the time of the inspection there were 44 people living at the service. Bedrooms are accommodated on the ground and first floor and are all single occupancy with en-suite facilities. There is a lounge, dining room and accessible bathroom facilities on both floors.

There was a registered manager in place. 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.

The provider had a range of checks in place to monitor the quality and safety of the service such as medication administration records, accident and incident records and people's care plans and monitoring records however these had not always been effective at identifying areas that needed improvement.

The provider had not ensured there was always sufficient numbers of relevantly qualified and experienced staff that had a good understanding of people's needs on duty. The service was heavily reliant on agency staff some of whom had not received an induction to the service. There had been no permanent nurses on duty at night during February 2018 and one night every week there had only been one permanent care assistant on duty.

The administration of medicines was not always safe. The provider could not be assured sufficient time had always been left between the administration of people’s morning and lunch time medicines. The guidelines for when ‘as and when needed’ medicines could be administered to people were not clear. This increased the risk of people not receiving their medicines as they needed them.

Risks to people were not always managed safely. Most people did not have a call bell to use when they needed assistance and sensor mats were not always positioned so they would be activated if the person moved. Risks of people becoming malnourished, developing pressure ulcers and experiencing falls had been assessed but were not always up to date and did not always reflect people’s current needs. This increased the risk of people not receiving care that met their needs.

The mood and behaviour of people with a history of being aggressive to others was not always being monitored. Therefore staff could not identify patterns in behaviour and take action to reduce the risk of incidents occurring. Although pressure relieving equipment was in place for people who had developed pressure sores, repositioning charts showed people were not always being repositioned on a regular basis.

The provider had not ensured that appropriate action to safeguard the people from abuse had always been taken. Incidents of people being verbally and physically aggressive towards others and incidents of poor staff practice had been reported to the registered manager and action taken to protect people from harm. However these incidents had not been always been referred to the local authority for them to consider under local safeguarding procedures or reported to CQC as required.

The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS), and people were bei

The inspection took place on the 6 and 7 July 2017 and was unannounced on the first day, and announced on the second. The service was last inspected in October 2014 and was rated as ‘good’ overall with a rating of ‘requires improvement’ in the ‘responsive’ domain, however we did not identify any breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Avandale Lodge is registered to provide nursing care and accommodation for up to 48 people. The service is spread over two floors and supports people living with Dementia, mental and physical health needs. At the time of the inspection there were 44 people living at the service.

The service did not have a registered manager in post. The manager in post had previously been registered with the CQC before giving up their registration in June 2017. 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.

In April 2017 there had been an outbreak of influenza within the service which had increased people’s dependency levels. This had also impacted upon staffing levels and the management of the service. The registered provider had not effectively implemented contingency measures to manage this situation. Because of this we have made a recommendation relating to the contingency measures employed by the registered manager in relation to events such as these.

People received their medication as prescribed. We reviewed a sample of people’s medication and found that the correct quantities were being stored. Protocols were in place for administering PRN (‘as required’) medication so that staff knew when to administer this. Where issues had arisen with people’s medication the manager had been proactive in following this up to address this directly with staff.

People were protected from the risk of abuse. Staff had completed training in safeguarding vulnerable adults and knew how to report any concerns they may have. There was a whistleblowing procedure In place which would enable staff to raise their concerns anonymously either inside or outside the organisation.

There were sufficient numbers of staff in post to meet people’s needs. Staff were able to respond to call bells in a timely manner, and during one incident they responded quickly and effectively to maintain one person’s wellbeing.

Recruitment processes were robust and helped protect people from the risk of abuse. Appropriate checks had been completed by the registered provider prior to a member of staff being employed to ensure they were of suitable character.

Staff had received the training the needed to carry out their role effectively. They had completed training in areas such as moving and handling, infection control and the Mental Capacity Act 2005 (MCA). There was also an induction process in place for new staff which prepared them for their role, and enabled the manager to monitor their performance to assess their suitability for the role.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in place within the service supported this practice.

Staff treated people with dignity and respect. People commented positively on staff and we observed examples of good interactions. People presented as being at ease and relaxed in the presence of staff.

People’s confidentiality was protected. Records containing personal information was stored securely in locked offices, which remained secure when not in use.

Care records were personalised and contained important information about the care and support that people required. These were reviewed on a monthly basis or where any developments occurred which meant these n

This inspection took place on 13 October 2013 and was unannounced. We arrived at the home at 9.30am and left at 7.30pm. The service met all of the regulations we inspected against at our last inspection on 9 December 2013.

Avandale Lodge is registered to provide personal and nursing care for up to 48 older people who have dementia. On the day of the inspection 45 people were living in the home.

The home has single room en-suite accommodation over two floors. Each floor has two lounges, a dining area and bathing and toilet facilities. There is also a secure garden, which has seating and tables.

The home has a registered manager who has been in post since 2007. 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.

The experiences of people who lived at the home were positive. People told us they felt safe living at the home, staff were kind and compassionate and the care they received was good. Relatives told us they had no concerns about the way their family members were treated. Some of the comments from relatives included, “Mum is very safe here” and “We can rest easy knowing mum is safe and secure”.

People were supported to have their nursing and personal care needs met. People spoke positively about the care and support they received. Comments included: “The staff are very caring”; “They’re very good”; “They look after me”. However, some people said they sometimes had to wait a while for assistance when staff were busy and staff confirmed this.

People received visitors throughout the day and we saw they were welcomed and included. People told us they could visit at any time and were always made to feel welcome. One relative said “Mum appears to be happy here and the staff always make us welcome”.

The staff ensured people’s privacy and dignity were respected. All rooms at the home were used for single occupancy, which meant that people were able to spend time in private if they wished to.

Bedrooms had been personalised with people’s belongings, such as photographs and ornaments, to help people feel at home. We saw that bedroom doors were always kept closed when people were being supported with personal care.

People remarked that the food was good. One person said, “The food’s very nice. We get a choice and there’s plenty of it”.

People’s needs were assessed and care plans were developed to identify what care and support people required, although some lacked detail. Information about any change in need was recorded in the monthly evaluation, but the care plan was not always updated to reflect the changes. The staff told us they had access to the care records and were informed when any changes had been made to ensure people were supported with their needs in the way they had chosen. However, staff also told us that they found the care files very repetitive, time consuming to complete and that it was difficult to find the information they needed quickly. This meant that people may be at risk of not receiving the appropriate care in the unlikely event there were staff on duty who did not know people’s care needs.

There were regular reviews of people’s health and the home responded to changes in need. People were referred to appropriate health and social care professionals to ensure they received treatment and support for their specific needs.

People could choose how to spend their day and they took part in activities in the home and the community. The home employed one activity organiser who engaged people in activities in small groups during the day. However, we observed that several people were dozing in the lounges, particularly in the morning. Staff said they would like to be able to spend more time chatting to people and assisting them to pursue personal hobbies and interests.

Staff received specific training to meet the needs of people using the service and received support from the management team to develop their skills. Staff had also received training in how to recognise and report abuse. All were clear about how to report any concerns. Staff spoken with were confident that any allegations made would be fully investigated to ensure people were protected.

People knew who to speak to if they wanted to raise a concern and there were processes in place for responding to complaints.

Some people who used the service did not have the ability to make decisions about some parts of their care and support. Staff had an understanding of the systems in place to protect people who could not make decisions and followed the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

There were processes to monitor the quality of the service and we saw from recent audits that the service was meeting their internal quality standards.

At the time of our visit there were forty five people with dementia living at Avandale Lodge Nursing Home. We used a number of different methods to help us understand their experiences. We spoke to eighteen people who used the service and four relatives, looked at records, spoke to staff and made observations of the support provided. Some comments made by the people who used the service were:

“It’s the best place I’ve been. They’re all great.”

“That’s a friend – she’s a very nice girl” (about a member of staff)

“She’s a good working sister. She says she loves me” (about a nursing member of staff)

The relatives we spoke to were happy with the care and support provided. They were very positive about the staff and the way in which they provided support.

We spoke to three staff who said that a good service was provided and that people were well looked after.

We observed positive interactions between the people who used the service and the staff. Staff were attentive, had a caring attitude and were supportive.

We found that there were practices in place to ensure that the people who used the service were respected and that they were involved in the delivery of the service they received as far as this was possible.

Records showed that people had been assessed before they began to use the service and they had a care plan in place detailing the support they needed and how staff were to minimise risks to their well-being.

The staff were provided with the support they needed to enable them to meet the needs of people with dementia.

We found that the service involved and communicated with health and social care professionals when they were needed to ensure the needs of the people who used the service where appropriately met.

There were systems in place to monitor the quality of the service for people who had dementia.

The information we gathered from five relatives indicated that they were happy with the care and support provided. They described the staff as caring and attentive.

We observed positive interactions between the people who used the service and the staff. Staff were attentive, had a caring attitude and were supportive.

We spoke to one health professional who supported people who used the service. They said that a good service was provided at the home.

There were practices in place to ensure that the people who used the service were respected and that they were involved in the delivery of the service they received as far as this was possible.

Records showed that people had been assessed before they began to use the service and they had a care plan in place detailing the support they needed and how staff were to minimise risks to their well-being.

The staff were provided with the support they needed to enable them to meet the needs of the people who used the service.

There were systems in place to monitor the quality of the service.

LINKs* had made a recent visit to the home. Their report gave a positive description of the services provided. They made some recommendations for improvements to which the manager has responded.

** LINKs are networks of individuals and organisations that have an interest in improving health and social care services. They are independent of the council, NHS and other service providers.