This inspection took place on 9 and 22 May 2018 and was unannounced.

At our last inspection on 17 and 18 January 2017, we found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the management had failed to have effective systems and processes in place to monitor the safety and quality of the service provided. 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 of effective, responsive, and well-led, to at least good.

At this May 2018 inspection we found a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to the governance of the service, and one new breach in relation to consent procedures.

Avery Lodge residential 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.

The care home accommodates 14 people in one adapted building. At the time of this inspection there were 13 people living in the service, some of whom were living with dementia.

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.

The registered manager had not ensured that all areas identified as requiring improvement at our previous inspection were completed promptly.

The registered manager had applied for Mental Capacity Act 2005 Deprivation of Liberty Safeguards (MCA DoLS) when people who lacked capacity to consent, had their liberty restricted. However, we did not see that a capacity assessments had been carried out in advance to determine that this was required, or how any restrictions would be managed. Consent forms relating to decisions about people’s care were generic to several people living in the service, and had not been reviewed since 2016.

There were audits in place to monitor the quality of the service provided, however, there was still no care plan audit to check the quality of the content. People’s records still did not show that they had been involved in the planning of their care, and review procedures were not robust or meaningful.

Risk assessments were completed to ensure that people were kept safe. However, we found that the level of information was not sufficient to ensure that staff had up-to date and clear guidance to help them support people safely.

Care plans were not person centred due to the format being used. The registered manager acknowledged improvement was needed, and had sourced a template which would allow for more person centred detail to be added. These were being implemented.

Staffing levels were not always sufficient to meet people’s physical, emotional and social needs. The registered manager had identified a need for additional hours during the day and was trying to recruit.

Activities were provided by care staff when time allowed. More detailed information on people's social care needs was required to inform individual needs and preferences for social activity, and we have made a recommendation about this.

The provider had improved some areas of the service to modernise rooms, and ensure decoration was updated. The provider told us that people were happy with the 'homely' environment and current decoration in the service. However, we advised that they reviewed some areas of the premises for the benefit of people living with dementia, and we have made a recommendation about this.

People’s end of life wishes were sought and advance care plans were in p

The inspection took place on 17 and 18 January 2017 and was unannounced.

Avery Lodge is registered to provide care for up to 14 people. At the time of the inspection 13 people were living at the home. The home supports older people some of whom are living with some forms of dementia or who have other mental health needs. The accommodation comprised of a largely Victorian building over two floors. The service was currently using one room as a shared room.

There was a 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 a 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 in June 2015, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to safe care and treatment and the need for consent. People’s medicines were not being stored safely and they were not always being administered in a safe way. The appropriate procedures were not being followed when some people’s liberty was being restricted. Best interest decisions were being made without following the guidelines of the mental capacity act.

At this inspection on 17 and 18 January 2017 we found improvements had been made in these areas, so the service was no longer in breach of these regulations. However at this inspection we found a new breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The manager did not have systems in place to effectively monitor the quality of care provided by staff. Staff training was not robustly monitored and staff knowledge was not tested to ensure the training they received had been effective. We found staff were not consistently responsive to people’s needs and staff didn’t always provide support to people in a person centred way. The manager did not have effective systems to ensure good practice was consistently embedded in the care provided. The shortfalls in governance arrangements constituted a breach of Regulation 17 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 full version of the report.

People did not have accurate and detailed reviews so people were not able to give constructive feedback about the care they received. People’s assessment records did not always fully detail people’s needs and risks. Records were not always audited to ensure they were of a good quality.

Staff did not have enough time to spend chatting to people or to engage with people in one to one activities throughout the day. The manager had not considered ways to encourage social stimulation other than planned events.

We have made a recommendation about the service putting systems in place to supervise and oversee staff practice.

The Care Quality Commission (CQC) is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. The service was depriving some people of their liberty in order to provide necessary care and to keep them safe. The service had made applications for authorisation to the local authority DoLS team. The service was working within the principles of the MCA. Staff had a good understanding about the need to seek consent from the people they were supporting.

We have made a recommendation about improving staff’s knowledge of DoLS.

People benefited from being supported by staff who were safely recruited. There was consistently enough staff to safely meet people’s physical needs at the time of this inspection.

The manager and staff understood how to protect people from the risk of abuse and harm. However, staff were not aware of outside agencies they could also report their concerns to.

People re

Avery Lodge Residential Home is registered to provide accommodation and non-nursing care for up to 14 older people, some with a diagnosis of mental illness. At the time of the inspection there were 13 people living in the home.

This unannounced inspection took place on 3 June 2015. The previous inspection was undertaken on 24 April 2014 and we found that there were two areas where the provider was required to make improvements. These were in relation to people giving consent before any treatment was carried out and the checks carried out when recruiting new staff. We found improvements had been made in both of these areas. However further improvements were needed regarding consent.

At the time of the inspection there was no 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. However the providers live in a private part of Avery Lodge and jointly manage the service.

People didn’t always receive their medicines as prescribed and safe practices had not always been followed in the storage, administration and recording of medicines.

The requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards were not being followed. This meant that people were being restricted from leaving the home on their own to ensure their safety but the correct procedures were not being followed to ensure this was done in line with legal requirements.

People felt safe and staff knew what actions to take if they thought that anyone had been harmed in any way.

People confirmed that there were enough staff available to meet their needs. The recruitment process had recently been changed to ensure that people were only employed after satisfactory references had been received. Staff were kind and compassionate when working with people. They knew people well and were aware of their history, preferences, likes and dislikes. People’s privacy and dignity were upheld.

Staff monitored people’s health and welfare needs and acted on issues identified. People had been referred to healthcare professionals when needed.

People were provided with a choice of food and drink. When needed people were supported to eat and drink and this was done in a dignified manner.

Care plans and risk assessments gave staff the information they required to meet people’s needs..

There was a complaints procedure in place and people felt confident to raise any concerns either with the staff or the manager.

The manager obtained the views from people that lived in the home, their relatives and staff about the quality of the service and if any improvements were needed.

We found two 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 the report.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This is a summary of what we found-

Is the service safe?

People we spoke with told us that the felt safe at the service. One person told us, "I am very happy, I really have no complaints at all. I can go into Great Yarmouth when I want to, I am well fed and well looked after." Another person we spoke with said," I am happy and I am safe. I feel well looked after and there is nothing I want for."

Risk assessments were in place to ensure that people were safe when out in the community and a mobile phone containing emergency contact numbers always available for people to take out with them. We saw that personal evacuation plans and safety measures were in place to be used in the event of emergencies.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

People told us that they were happy with their care. Care records we looked at were up to date to ensure that staff had current information about the people they supported and showed that people's health and social care needs were being met.

The recruitment processes that were followed by the provider were not always effective. They did not ensure that the necessary information and detail was in place.

Quality assurance measures were in place to identify the effectiveness of the service. This included surveys of people who used the service, relatives, staff and visiting professionals and audits of infection control measures and medication. Details of further management checks that had just been introduced were shown to us. These will further improve the effectiveness of the service.

Is the service caring?

People who used the service told us that they were well cared for. They were happy with the staff team and with the care provided. They told us that the food was good with a choice available. Two people we spoke with told us that they liked spicy food and the chef, “Often makes us a nice curry.” We also spoke with a relative visiting at the time of our inspection. They were very satisfied with the overall care and support their family member received. They told us that they thought “The care is excellent, all my requests for information are answered and the care team are brilliant. My (relative) is treated with dignity and respect at all times.”

Is the service responsive?

Records showed that an assessment of people's needs was completed before they moved to the service. This showed the person’s assessed needs and linked to their care plan, which detailed how those needs were to be met.

People were able to access community facilities outside of the service and were supported by staff when necessary. Some people went to their local church, shops, pubs and restaurants independently and were supported in maintaining this independence.

Is the service well-led

The service was managed by one of the owners. However, at the time of the inspection an application was still awaited to formalise their registration.

The owners lived on the premises and were available at any time in the event of a problem. Arrangements were in place for either additional staffing at night or alternative on call facilities when the owners were not available.

Staff we spoke with told us that they felt well supported and records showed that regular supervision was now taking place.

During our inspection we spoke with seven people who used the service about the support they received. They were all very happy living at Avery Lodge. One person told us that, "It is marvellous." Another person we spoke with told us, "They (the staff) will always listen to me and if something is wrong they put it right."

We looked at the care records held by the service. These were comprehensive, but some areas requiring improvement were noted. We also looked at staff recruitment and training records and maintenance records which were all clear and well managed.

Robust recruitment procedures were followed to ensure that suitable staff were taken on to support and care for people who used the service.

During our inspection we spoke with five people who used the service and with three members of staff. We also spoke with the deputy manager and provider.

People who used the service told us the care they received was very good. One person described it as, "Brilliant." Another person told us that staff, "Always check to see if I need medication and watch me while I take it." We were told the food was very good, and one person told us they had, "No complaints at all."

The staff we spoke with told us about training they received to help with their job including induction training for new starters.

We spoke with eight people throughout the morning of our inspection. One person said, “My health care needs are met and I see the doctor when necessary. Staff sort out my tablets, the meals are good and I had a bath and hair wash this morning.” We asked about activities and they told us they only joined in when they felt well enough too and liked to be quiet. Two other people told us what activities had taken place in the last few weeks, including a jubilee party and raffle. They went out weekly to church and bingo. One person said,” The carers are really good and the call bell is answered immediately.” They said staff supported them to have a bath and they received regular meals and snacks.

One person said there were a variety of activities and events, the day before the visit they had an ‘Elvis’ tribute which they enjoyed.

People with whom we spoke told us that they were asked by the staff for their view about the service and how it could be improved. Some people said that they were invited to attend residents meetings and had been asked to complete a questionnaire.

One person with whom we spoke said they enjoyed living in the home and were able to make their own decisions about how they wished to live their lives. We spoke with people about the choices they were offered at mealtime and they told us that they were happy with the food provided.

People also told us that they were happy with the care and support that they received, they had their needs met and were treated with respect.