Avalon Cypress Road

Updated 1 March 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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 1 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Cypress Road is a respite service. It provides accommodation and personal care to people on a temporary basis. 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 the Care Quality Commission 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

We gave the service 24 hours’ notice of the inspection. This was because the service is small and people are often out and we wanted to be sure there would be people at home to speak with us.

What we did before the inspection

We used information gathered as part of monitoring activity that took place on 24 April 2022 to help plan the inspection and inform our judgements. We requested feedback from stakeholders, including the local safeguarding and commissioning teams. 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 observed the care of 1 person. We spoke with 2 people who used the service and 5 relatives about their experience of the care provided. We gathered feedback from 6 staff members including the registered manager, regional manager and care staff.

We reviewed a range of records including; 5 peoples care plans and risk assessments, 2 people’s medicines records and 3 staff files in relation to recruitment. We reviewed a variety of records relating to the management of the service, including policies and quality assurance records. Following the site visit, we reviewed further information and evidence from the provider. This included information relating to meetings and surveys, training and audits.

Updated 1 March 2023

About the service

Cypress road is a respite service providing accommodation for up to 4 people, who require personal care. The service has approximately 25 people who access the service over a 12-month period. The service provides support to people who have physical health needs, learning disabilities and autistic people. At the time of our inspection there were 2 people using the service.

The service is set out across 1 floor, with capacity to separate the service in to 2 units. There is a kitchen, dining room, lounge, communal bathroom and sensory room dividing the 2 units. Each bedroom had an en-suite facility. The service had an office with a sleep-in facility for staff.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

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. People's support needs and risks were assessed to identify how their care could be provided safely.

Right Care:

People received kind and compassionate care. Staff had received appropriate training, knew people well and supported them in line with their preferences. People’s care plans were detailed and reflected people’s choices. Peoples medicines were managed safely.

Right Culture:

Feedback from people, relatives and staff was mostly positive about the care received. Care provided was person-centred and people were encouraged to make decisions around their care. The service worked in partnership with other health and social care professionals to ensure people’s care was effective. The provider was working to improve the culture at the service and the robustness of newly implemented governance processes, including more regular and robust audits.

We have made a recommendation about the embedding of governance processes.

Recruitment was managed safely. The service was well maintained and accommodated people’s physical and sensory needs. The service had not received any formal complaints but had a process in place to support this.

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 requires improvement (published 09 December 2019) and there was a breach of regulation. At this inspection we found improvements had been made and the provider was no longer in breach of regulations. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

Why we inspected

We undertook this focused inspection to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cypress Road on our website at www.cqc.org.uk.

Recommendations

We have made a recommendation about embedding newer quality assurance processes to improve the culture and governance at the service.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.