Averill House

Averill House is a nursing and residential care home providing personal and nursing care to up to 48 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 47 people using the service.

Averill House is a purpose-built care property with 3 floors. The ground floor provides residential support, and the first floor provides nursing care. Each floor has two lounges, dining room and adapted bathing facilities. The third floor has a large kitchen and laundry.

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

Medicines were not always safely managed. The home took actions to rectify the issues we found following our inspection. A quality assurance system was in place and actions completed for any issues identified. However, the medicines audits had not been robust in identifying the issues we found during this inspection.

People felt safe living at Averill House. Risks were identified and guidance was in place to manage them. There were enough staff to meet people’s care and support needs. Staff were safely recruited. Equipment was regularly checked and serviced in line with legal guidelines. Incidents and accidents were reviewed for any learning to reduce further occurrences. The home was clean throughout, and infection control was well managed.

Staff said the management team were visible in the home and approachable if they needed to speak with them. The home worked well with a range of professionals, including physiotherapists, GPs and district nurses.

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 and relatives said they were involved in agreeing and reviewing their care plans. Relatives said there was good communication with the staff team and any concerns they had were addressed. Staff said they enjoyed working at the home.

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

Rating at last inspection

The last rating for this service was good (published 20 December 2018).

Why we inspected

We received concerns in relation to the management of medicines and people’s nursing care needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

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.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report. Action had been taken to address the issues we identified.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

We have identified breaches in relation to the safe management of medicines at this inspection.

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 last inspection of this service was on 12 and 13 September 2017 where we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as the provider had not assessed the risks behaviours posed to other people. Following the inspection, we asked the provider to take action and told the home to produce an action plan to address the issue we had found. At this inspection, we found there were improvements to risk assessments to mitigate the risks behaviours posed to others. Further information can be found in the body of the report.

Averill House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Averill House is a modern purpose-built property which can accommodate up to 48 people. There were 44 people living at the home on the dates of inspection. The home is divided into three floors. People are supported on the ground and first floor and a large kitchen and laundry facilities are situated on the third floor.

The service had a registered manager in place. A registered manager is a person who has registered with CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was supported by a deputy manager, both managers assisted with the inspection.

People felt safe living at Averill House and were aware of how to raise any concerns they had. Staff members were aware of their responsibilities in relation to protecting vulnerable adults from abuse and were confident the registered or deputy manager would act on any concerns they had. All staff had received safeguarding training.

Staff members were recruited safely and received a robust induction to introduce them to their role. Staff received regular supervision and attended staff meetings to ensure they were kept up to date with changes and had the support to carry out their role effectively.

Premises safety was well managed. Regular external checks took place of equipment such as the firefighting systems, the passenger lift, moving and handling equipment and electrical and gas safety. Internal checks on premises safety were completed weekly or monthly and clearly documented.

People had appropriate risk assessments in place to support them. Risk assessments were reviewed regularly or when needs changed. They identified strategies to support people to minimise risk.

Accidents and incidents were fully documented, and lessons learned were shared to prevent future occurrences.

Medicines were safely managed. Audits were in place to monitor the safe receipt, storage, administration and documentation of medicines. Staff received training to enable them to administer medicines safely.

Staff received training suitable for their job role. The provider supported staff to complete diplomas in health and social care to expand their knowledge. We saw all staff received an induction and were given the opportunity to shadow more experienced members of staff.

The service was working in line with the Mental Capacity Act 2005. People received appropriate capacity assessments and decisions were made in people’s best interests. People were only deprived of their liberty where applications had been made to do so.

People were supported to eat a healthy and nutritious diet. People were very complimentary of the food and were supported to eat a diet from their cultural background should they wish.

People received input from primary care services such as a GP or dentist. The service was part of a project to enable people in the home to be diagnosed and treated promptly. The project was working to reduce admissions to hospital and involved weekly reviews of peoples health.

We observed caring and dignified interactions between staff members and people living at the home. People told us they felt cared for and staff always ensured their privacy and dignity and encouraged independence.

Care plans captured people’s support needs and were person centred. People told us they had been able to contribute to their care plan and we saw people’s choices, likes and dislikes were clearly recorded. Care plans were regularly reviewed to ensure they were current.

Activities were varied, and people were supported to attend social groups and one person was supported to enable them to meet people from their own culture.

People were supported to remain at the home at the end of their life. The service worked with district nurses and other professionals to ensure people were supported to be pain free and had their choices respected at the end of life.

Audits to monitor and improve the service were in place. Audits worked to highlight areas for improvements and action plans were then developed to ensure the improvements were made in a timely manner.

People and staff members told us they felt well supported by the registered manager. We observed the registered manager was visible across the home throughout the inspection, and offering support to people, staff and relatives. The registered manager felt well supported by the area manager.

Averill House is a purpose built care home providing accommodation, with nursing care, for up to 48 older people. The home specialises in care for people living with dementia. People live on two separate floors, each with its own dining room and lounges. The first floor caters for people who require nursing care.

The home did not have a registered manager. 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. There was a relief manager in place who was present throughout our inspection. The provider had appointed a new manager who was undergoing their induction into the service and was also present on the second day.

People told us that they felt Averill House provided them with a safe environment, and the building was secured in a way that minimised people’s movements. We saw that appropriate action was taken by the service to investigate any allegations of abuse with protective measures in place to limit or prevent avoidable harm.

During this inspection we identified a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment. Whilst risks were generally identified, we found a risk to a number of people who used the service had been overlooked. Where care plans provided general instruction for staff to minimise risks, we found they did not always provide enough instruction to staff, or actions taken were not fully documented.

There were sufficient staff to meet the needs of people who used the service, a low staff turnover and minimal use of agency staff. This meant that people were supported by staff who had got to know them and could respond in a person centred way. Staff were well trained; there was a good induction system for new staff to get to know the people who used the service and the daily routines of Averill House. Staff took advantage of on-going training and received regular supervision. We saw that they communicated well with each other before and during each shift.

We saw that people were always offered a choice and their wishes were respected. Where people lacked capacity we saw evidence that some decisions taken on their behalf were made in consultation with the person’s representatives. However, some decisions made on behalf of people – whilst taken in their best interests – were not evidenced or accounted for in case notes.

People told us they enjoyed the food at Averill House. We saw that the meals offered were balanced and nutritious and followed the dietary requirement of people who used the service. Where people required input from health and social care professionals such as nurses or Speech and Language Therapists we saw evidence of liaison and appropriate recording of instructions within care files.

People were treated with patience, and their views were respected. When we spoke with staff, they were able to tell us how they would address any specific cultural needs. Interventions were good, but often based on need, so opportunities for staff to engage with the people who used the service were sometimes missed.

We saw that care and support needs were addressed in a person centred way, but poor recording of interventions did not always reflect this. When we spoke with people who used the service they told us they were happy with the support they were offered. They and their family members told us that they were consulted on their care plans, and we saw that plans were regularly reviewed.

People who used the service and their visitors also told us that the service regularly sought their views, and we saw that customer feedback was taken into consideration to improve the quality of care. The service conducted regular audits, and there were good systems of quality assurance in use to ensure the safety and well-being of people who used the service.

When we spoke with staff they told us that they enjoyed working at Averill House, and there was a high level of morale. Staff were invited to regular staff meetings and we observed a good team spirit, especially on the nursing unit. Whilst staff were clear on their roles and responsibilities we saw that all staff supported and assisted one another to ensure the well-being of people who used the service, including none care staff such as domestic and kitchen staff.

The previous inspection had been on 24 September 2014, and the inspection before that on 28 April 2014. At the April 2014 inspection we found the service was not meeting two regulations, relating to reporting safeguarding allegations, and staffing levels. At the September 2014 inspection we found that the service had improved and was now meeting those two regulations.

Averill House is a purpose built care home providing accommodation, with nursing care, for up to 48 older people. At the start of this inspection there were 32 people living in the home, and two more people arrived on our first day. The home specialises in care for people living with dementia. People live on two separate floors, each with its own dining room and lounges. People with needs classed as 'residential' live on the ground floor. The first floor caters for people who require nursing care. Two people with nursing needs were living on the ground floor in line with their family's wishes. There is a car park within the grounds. The home is situated in the Newton Heath area of Manchester, close to local amenities and with good transport links.

There was a registered manager who had started working in Averill House in December 2014. 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.

We saw that the building was spacious and suitable for the needs of the people living there. However, due to its size it was difficult for staff to monitor all parts of the building especially at night when there were only two staff on duty on each floor. We knew of an accident that had happened unobserved in the ground floor corridor causing an injury that required hospital treatment. One of the two staff on duty had been upstairs at the time. We considered that this meant that the provider had not done everything reasonably practical to reduce risks. This was a breach of the relevant regulation.

We noted however, that the registered manager had acted to try and prevent a recurrence of this accident, by purchasing a chair sensor. This relied on staff being nearby when the person got out of their chair.

We saw that recruitment processes were robust, and that staff were trained in safeguarding and knew what to do if they had any concerns about abuse.

Records showed that staffing levels had been increased during 2015 by one staff member on the day shift. Given the complex needs of some of the people, all of whom were living with dementia, and the size of the building, the registered manager needed to regularly reassess the numbers of staff required. We considered that there were sufficient staff on duty. We were concerned that one member of staff was working excess hours.

We were satisfied that medicines were managed safely and properly. The home was clean. There was a smell of urine on a downstairs corridor but the carpet was due to be replaced with laminated flooring in a refurbishment. We saw that the building was maintained to be a safe environment and there was a refurbishment planned in the immediate future.

Training was up to date and a high percentage of staff had completed both mandatory and additional training. Most training was by e-learning on the computer but there was some classroom training as well. Some staff had completed training in dementia care. We have recommended that training in dementia care be reviewed and improved and delivered to all staff.

We saw the supervision schedule for 2015. The schedule required that staff receive supervision at least six times a year, but this had not always happened during 2015.

We checked whether Averill House was working within the principles of the Mental Capacity Act 2005 (MCA). We saw that the correct procedures to obtain consent were followed, where the person lacked mental capacity.

There were three people whose liberty was being restricted under a Deprivation of Liberty Safeguards (DoLS) authorisation. Six other applications under DoLS were awaiting a decision.

We saw that the food was nutritious and was enjoyed. It did not match what was on the menu. The dining rooms were pleasant places to eat, although we noticed that the posters on the wall were not really for the benefit of people living in the home. There was scope to make the visual environment more suitable for people living with moderate to advanced dementia.

Relatives made mainly favourable comments about the care provided in Averill House. We observed kind and considerate gestures by staff towards people living in the home.

We received information of concern about the provision of care and treatment to people who were at risk of pressure sores and found that the care and treatment of pressure areas could be improved. This was a breach of the relevant regulation.

On the whole staff treated people with respect. We noted that some disrespectful language was used about people, but it was not malicious. People’s dignity was upheld, and the registered manager had a considered policy about intimate relationships. Family members were encouraged to be involved in the care of their relatives.

There had been a serious safeguarding issue in December 2014 regarding a failure to provide proper end of life care. Since then training in this area had improved, but there was room for further improvement.

There was a comprehensive set of documents in the care plans but we found little about each individual’s personal history. Some booklets had been introduced to fill this gap but had not yet been completed. The care plans were reviewed regularly but we found some errors in them.

Several care staff, including someone who had worked at Averill House for over a year, told us they had not read any care plans. This meant that people were at risk of receiving inappropriate care and or treatment. This was a breach of the relevant regulation.

Averill House had an activities co-ordinator. An outing was arranged on the first day of our inspection but had been badly planned, without a risk assessment. We observed that people were not always engaged in appropriate activities.

Surveys of relatives were conducted annually and meetings took place quarterly. Relatives were given the opportunity to contribute ideas to the running of Averill House. We saw that complaints were responded to promptly.

The registered manager was supported by the provider who supplied a comprehensive set of policies and procedures. Within the home there was a management team and good communication among the senior staff. Staff meetings were not well attended which meant that issues discussed there were not necessarily shared with all the staff, although the minutes were displayed after the meeting.

There was a system of regular audits, which the provider monitored. Lessons were learnt from accidents and incidents, and from any physical encounters between people living in the home.

We learnt that the registered manager had acted firmly in relation to a disciplinary issue in order to protect people living in the home.

In relation to the breaches of regulations, you can see what action we told the provider to take at the end of the full version of the report.

We spoke with the relief home manager, and looked at files and records to check whether the action plan sent to us after the last inspection had been implemented.

In relation to safeguarding, we saw evidence that staff had received refresher training in safeguarding issues, and were better equipped to identify and report any instances or suspected instances of abuse.

In April we found that staffing levels in the daytime had gone down compared with the previous year. There was one person who was receiving 1:1 care in the daytime but there was no extra staff provision to cover this. We found a letter from night staff setting out reasons why the staffing level at night was too low. No action had resulted from this letter. At this inspection we found that action had been taken to focus staff where they were needed. The night staffing level had been increased.

We therefore found that the provider was now compliant with the standards which we looked at.

We set out amongst other things to answer five key questions: "Is the service safe? Is the service caring? Is the service responsive? Is the service well-led? Is the service effective?"

The evidence that supports this summary can be found in our full report.

Is the service safe?

We were concerned that there were not always enough staff available to maintain a safe environment. In one area of the home there were a number of people whose behaviour could be challenging. We considered that more staff were needed both in the daytime and at night in order to ensure that those people and those around them were kept safe.

The home had four people subject to restrictions on their liberty which had been authorised under the deprivation of liberty safeguards (DoLS). Relevant mental capacity assessments had been completed.

We found that Averill House had not always correctly reported safeguarding incidents.

Is the service caring?

One family member replied to a survey: "My relative was in a bad way when she entered Averill House, now she is in very good health. Due entirely to the care she received from everyone at Averill House."

We observed that the staff were dedicated to looking after the physical needs of people. Care plans were comprehensive. We considered that there could be greater response to the specific needs of people living with advanced dementia.

Is the service responsive?

The provider had a detailed and thorough system for inspecting and improving the quality of the service, and responded to events in a positive way.

Is the service well-led?

The registered manager was supported by a deputy manager and a staff team. There was close oversight by the quality assurance manager and other staff of the provider. The provider had a detailed set of policies and procedures, which the registered manager and other staff were required to follow in detail.

Is the service effective?

We saw that people were well-cared for, so the service was effectively fulfilling its main purpose. We found there were some areas for improvement, in terms of reporting safeguarding events and in improving staff numbers.

The home was meeting all the outcomes we looked at on this inspection.