Averlea Residential Home

Updated 2 December 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

This was a targeted inspection to check whether the provider had met the requirements of the Warning Notices in relation to Regulations 11 (Consent), 12 (Safe care and treatment), 17 (Good governance) and 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Inspection team

The inspection was carried out by 2 inspectors.

Service and service type

Averlea Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Averlea is a care home without nursing care. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with CQC to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority quality monitoring team. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 3 people who used the service about their experience of the care provided. We spoke with 4 members of staff including the registered manager. We also spoke with the provider.

We observed support and interactions between people and staff in communal areas. We reviewed a range of records. This included Medicine Administration Records, 3 people's care plans, training records, meeting notes, and accident and incident records.

Updated 2 December 2023

About the service

Averlea Residential Home is a care home providing personal care to up to 14 people. The service provides support to older people some of whom may be living with dementia. At the time of our inspection, there were 7 people using the service.

People’s experience of using this service and what we found

This was a targeted inspection that considered staffing levels and staff support, compliance with the Mental Capacity Act and the management and oversight of the service. Based on our inspection of these areas we concluded the following:

Staffing levels were sufficient to meet people's care needs. The provider was sometimes working at the service to fill any gaps in the rota. At the time of the inspection there were only 7 people living at Averlea. The registered manager and provider told us they would use a dependency tool to ensure they were able to meet people’s needs before admitting any new residents.

Staff had completed training in areas including safeguarding, manual handling and medicine administration. More training was arranged to further staff skills and knowledge. The registered manager had yet to complete competency checks to assure themselves staff were applying their learning.

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

Improvements had been made to the recording of the administration of medicines. Protocols had been developed to support staff in the administration of medicines to be used as required, such as pain relief. There were some errors in recording and administrating medicines which require stricter controls and we have made a recommendation about this in the report.

At the time of our previous inspection, the registered manager was working in the kitchen to prepare meals for a meal delivery service in the community. They had since rearranged their work responsibilities to concentrate on their managerial duties. There were no senior roles to support the service if the registered manager was not at work.

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

Rating at last inspection and update.

The last rating for this service was inadequate (supplementary report published 26 October 2023).

At this inspection we found some improvements had been made. However, the provider remains in breach of Regulation 17 (good governance).

Why we inspected

We undertook this targeted inspection to check whether the Warning Notices we previously served in relation to Regulations 11, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Enforcement and Recommendations

We have identified a breach in relation to the oversight and governance of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.