The inspection took place on 14 November 2017 and was unannounced. At our last inspection we found a breach of Regulation 13 in relation to the process for applying for Deprivation of Liberty Safeguards authorisations. When we returned to the service we found that action had been taken to address this breach. At our last inspection we rated the service as Requires Improvement, at this inspection we rated the service as Good.

Avenue House provides residential care and accommodation for up to 30 people. 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. At the time of our inspection there were 28 people living at the home. The service is provided by a Quaker organisation; however people of all backgrounds and faiths can use the service. 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.

At our last inspection, we found that the procedures had not always been followed when a person needed Deprivation of Liberty Safeguards (DoLS) in place. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection, the registered manager submitted an action plan to show how they would address the shortfall. At this inspection, we found that the action had been taken and the service was no longer in breach.

We found that people living in the home were positive and happy with the care they received. They told us that staff treated them well and with dignity and respect. This was reflected in our observations. People and their families were involved in decisions about care and about the running of the home. There were plans in place to involve people further in directly influencing developments in the service. The business plan contained an objective to have at least three service users on the board of trustees by 2018.

People received care that was safe. Medicines were stored securely and there were processes in place to record their administration. We did find some errors with stock levels of some medicines, however this was rectified promptly following our inspection and evidence sent to us to confirmed that this had been done. There were enough staff to ensure people’s needs were met safely and when new staff were recruited, checks were carried out to ensure their suitability. Improvements had been made in how the service managed safeguarding referrals. Concerns were shared with the local authority when necessary.

The service was effective at meeting people’s health needs. If there were concerns for example about a person’s nutritional intake, then this was monitored and plans put in place to support the person. People’s GP and other healthcare professionals were involved in people’s care. Staff were well trained and received regular supervision to ensure they were able to carry out their roles effectively.

People received personalised care that met their needs. A pre assessment took place prior to the person arriving at the home and this helped staff create suitable care plans for people. Care plans covered a range of needs, including nutrition, moving and handling, personal care and emotional needs. People were able to take part in a range of activities if they wished to do so. There was a procedure in place for managing complaints.

The home was working towards the Gold Standards Framework accreditation. This is a framework that supports a service to provide high quality care at the end of people’s lives. The registered manager spoke enthusiastically and positiv

The inspection took place on 1 and 2 November 2016 and was unannounced. The last inspection took place in August 2014 and no breaches of legislation were found at this time.

The home provides care and accommodation for 30 people. There is 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.

During our inspection we found that people weren't safe in all aspect of their care. There was a lack of plan in place to describe when a safeguarding alert should be made in relation to unexplained marks and bruises on a person's skin. We also found there was no recording system in place for the administration of prescribed creams.

The home wasn’t effective in all aspects. This was because an application under the Deprivation of Liberty Safeguards (DoLS) had not been made for an individual that required it. The Deprivation of Liberty Safeguards provide a framework to assess the needs of a person who may require a derivation of their liberty in order to receive care and treatment

People reported feeling safe and well cared for in the home and had pendant alarms that allowed them to call staff for help if needed. There were sufficient numbers of staff to meet people's needs and for staff to spend time with people outside of care tasks.

People made positive comments about the staff and told us they felt very well cared for. Comments included “nothing I could find fault with”, “exceptionally happy place to be” and “very well looked after, I feel like the queen”. People were strongly involved in planning and reviewing their own care and support. People's views and opinions were also taken in consideration in the running of the home. People were positive about the food and meals provided at the home. People's weight was monitored in order to identify any potential concern about a person's nutrition.

Staff received support and training to carry out their roles. Staff told us they felt very well supported by the registered manager and could raise issues or concerns at any time. There was a procedure in place to manage and respond to complaints. There were taken seriously, investigated and resolution reached to the satisfaction of the person raising concerns.

There was a programme of quality monitoring in place and where issues were identified as a result of this action was taken to improve the service. During quality monitoring an issue in relation to the vegetarian meals on the menu was identified and as result meetings were organised between people in the home and the chef.

A single inspector carried out this inspection and spoke with 14 people who used the service, one visitor, the registered manager and three care assistants. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found which describes what we observed, what the staff told us, and the records we looked at.

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

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. There were enough staff on duty to meet people's needs. Care planning was comprehensive and reflected the individual needs of people. There was evidence of care plans being amended to reflect the changing needs of people.

People told us "I feel very safe here" and "I feel perfectly safe".

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. The registered manager understood when an application should be made, and how to submit one.

Is the service effective?

People told us "the care staff are excellent" and "this is the next best place to home". It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well. One person told us "I'm very impressed with the access to doctors; you know the staff will get help and advice from them when needed".

Staff had received training in order to carry out their roles effectively.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. People told us "the care staff are excellent" and "this is the next best place to home". One relative told us "the first time I came here I was very impressed. The staff are very caring and always smiling".

The atmosphere was calm and unhurried. One member of staff told us "if someone wants to chat I spend time with them; it's good that we get time to talk to people".

Is the service responsive?

People’s needs had been assessed before they moved into the home. Records confirmed people’s preferences, interests, and diverse needs had been documented and care and support had been provided that met their wishes. People had access to activities that were important to them. Where possible, people were able to be as independent as possible.

People told us "there is lots of activities but if you don't want to get involved you don't have to" and "it's like a small hotel".

Is the service well-led?

Staff told us they felt well supported by the registered manager. Quality assurance processes were in place to regularly monitor the service. People told us they were asked for their feedback on the service they received and that they had also filled in a customer satisfaction survey. They confirmed they had been listened to and as a result of the survey changes to the menu had been made. Staff told us they were clear about their roles and responsibilities.

One relative told us "the staff are very professional; the manager leads by example".

At our last inspection in November 2013 we found that people were not fully protected against the risks associated with medicines because the arrangements in place for the recording and safe administration of some medicines were not always followed. The provider sent us an action plan stating how they would address this. We found that suitable action had been taken so that people were protected from the risks associated with medicines.

People who used the service were given appropriate information and support regarding their care. This meant people were able to make an informed choice about their care. People told us the manager had visited them to find out about their needs before they moved into the home. One person told us” the manager came to see me before I came to live here to make sure they can help me”.

People's needs had been assessed and care and support was planned and delivered in line with their individual care plan. One person told us, "I signed my care plan". We observed staff treated people in a respectful manner.

People's independence had been encouraged and they were enabled to do as much as they could for themselves. One person told us, "The staff let you do as much as you can do for yourself. I am quite independent and I like doing things for myself”.

We found people who used 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. One person told us “I feel safe here. I have no complaints”.

We found that people were not fully protected against the risks associated with medicines because the arrangements in place for the recording and safe administration of some medicines were not always followed.

We found the people who used the service, their representatives and staff were asked for their views about the care and support and they were acted on.

There were 28 people living at Avenue House when we visited. We met with 15 people and spoke with them to find out their views of the service.

We spoke with the registered manager and three care workers. We talked with them about what they did to effectively support people who used the service.

People told us they were happy at Avenue House and they had positive opinions about the service they received. Comments we received included, “it’s wonderful here”, “the staff are very kind they are like extended family”. People also told us, “I have great praise for this place”, and “it almost feels like home here”.

People’s needs were effectively met by enough suitable and competent staff at Avenue House.

People were encouraged to make their views known about the care and service at the home. When complaints were made, these were properly investigated and suitable action was taken by the provider to address matters.

All people told us that they were happy at Avenue House. They told us that they experienced good care at the home and that staff always asked their consent before they were provided with care and treatment. They said that the contract was explained to them before they signed it and that they had a choice about how they received care or treatment.

People we spoke to living in the home told us that they were assessed before admission to ensure that the home was able to meet their needs. They told us that they were involved in drawing up their care plans and that they signed them afterwards. People said that they were registered with the doctor, dentist, and optician and have access to other health professionals if required. They told us that staff would always informed them before their information was shared with anybody.

People said that the food was very good and that they had a choice of what to eat and when to eat every day. We were told that the menu was changed every four weeks to give people more variety. They told us that there were different activities in the home. People said that they felt safe living in the home, they had access to their money when they wanted it and that this was kept securely. They said that they had access to their records whenever they wanted to.

People told us that their rooms were always clean and that in general the home always looked good. The said that cleaners were always available and there were no unpleasant odours.

We were told that staff ordered their medicines for them and that it was given at the right time, and that it was always kept safe.

People said that there was enough staff everyday to meet their needs and that when they used the call bell to summon help that staff attended to them promptly. They told us that experienced respect, loyalty and kindness from staff and were given the support that they needed. One person said "I think when somebody is ill they put more staff to help us"

People told us that they had no complaints. They said that if they were not satisfied with the services they would let their key worker know. They said that the manager’s door was always open and that she was very approachable and always took out time to listen to any concerns if any.

One individual represented the view of many people living in the home when the person said” the home is good you are treated like a human being, I am very happy. Staff are excellent, I have confidence in them all, and I know I am in the right place."