Avalon House

Updated 18 January 2020

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 Care Act 2014.

Inspection team

This inspection was carried out by an inspector and an assistant inspector on both days of the inspection.

Service and service type

Avalon House 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.

At the time of the inspection the service did not have a manager registered with the Care Quality Commission although the manager advised she was due to be interviewed for the role by the CQC shortly. The registered manager and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of publication of this report the manager has now become a registered manager with the CQC.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service before the inspection. We sought feedback from the local authority who work with this service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection

We spoke with three people. We spoke with the manager, the deputy manager and four staff members. We also spoke with a healthcare professional on the phone during the inspection.

We reviewed a range of records. This included five people’s care records and five medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including training and quality monitoring records were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 18 January 2020

About the service

Avalon House is a residential care home providing personal care to people who are living with mental health conditions. At the time of the inspection five people were living at the home and the service can support up to 10 people. The care home accommodates people in an adapted building which is set over two floors.

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

People did not always receive safe care. The risks associated with people’s care had not consistently been identified and plans were not always in place to minimise these. People were supported by staff who understood the appropriate action to take should they be concerned about their safety. Staff had been recruited safely although we found improvements were needed to ensure the recruitment process became more robust. People were supported to take their medicines safely although we found improvements were needed in the record of medicine administration.

People received effective care. People were supported to have maximum choice and control of their lives and staff them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were supported to receive appropriate healthcare in line with their specific needs. Staff had received training around people’s needs. People were supported to eat and drink meals of their choosing and were encouraged to develop life skills around preparing meals.

People received support that was caring, compassionate and kind. People were involved in all aspects of their care. People had their dignity and privacy respected. One of the key aims of the service was to develop people’s life skills. People told us, and we saw that this enabled people to have their independence promoted.

People received care that was responsive to their needs. People had been involved in stating how they wanted their care to be delivered. People had activities available to them based on their individual interests. People were able to raise concerns and be assured these would be investigated.

The service was not consistently well-led. Whilst systems were in place to monitor the quality and safety of the service the provider’s systems needed to become more robust to enable all aspects of the service to be monitored. Staff were able to feedback their views of the service and felt supported. The manager acted openly and responsively during the inspection ensuring they took immediate action to remedy any areas of improvement we identified.

Rating at last inspection

This service was registered with us on 14 November 2018 and this is the first inspection.

Why we inspected

This was a planned inspection.

Enforcement

We have identified breaches in relation to the safety 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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