This inspection took place on 22 February 2018 and was unannounced.

At the last comprehensive inspection in October 2016 we rated the service overall Good, but the key question ‘Safe’ was rated requires improvement and the provider was in breach of the Health and Social Care Act Regulations 2014. This was because people’s medication was not always managed in a safe way, and staff recruitment procedures did not ensure agency staff were safe to work at the service. We asked the provider to send us an action plan to tell us how they planned to make the necessary improvements.

In January 2017, we carried out a focused inspection to check the actions taken by the provider to improve the medicines management and staff recruitment procedures. We found the necessary improvements had been made and the breaches in regulations had been met. However, the rating remained ‘Requires Improvement’ under the key question ‘Safe’ as we needed to see consistent good practice over time.

Avenue House Nursing and Care 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 service had 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 was still working at the service, however they had taken on another role within the company and a new manager had recently been appointed and planned to submit a registered manager an application with the Care Quality Commission (CQC) to registered manager for the service.

The provider had identified shortfalls in terms of their use and storage of hazardous cleaning chemicals and had taken appropriate action to mitigate any individual and environmental risks. They had also taken action to assess the nursing staff competencies. However, more time was needed to ensure their actions to improve the service were fully embedded into practice.

The area used to store moving and handling equipment was cluttered and disorganised, which meant equipment was not always accessible and readily available for use.

There were enough staff employed to meet people’s needs and the staff recruitment procedures ensured that appropriate pre-employment checks were carried out to ensure only suitable staff worked at the service.

People received their medicines safely and as prescribed. There were systems in place to ensure the premises were kept clean and hygienic so that people were protected by the prevention and control of infection. When things went wrong, the provider analysed the cause to learn from incidents to improve safety across the service.

People’s care needs were assessed prior to moving into the service. Staff received induction training on commencing work at the service and they received on-going training to ensure they were able to provide care based on current good practice guidance. People had their nutritional needs assessed and were provided with a choice of nutritious meals. People were supported to access health appointments and referred to other healthcare professionals in response to their changing needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People had good relationships with the staff who were caring and treated people with respect, kindness and courtesy. People were encouraged to make decisions about how their care was provided and staff had a good understanding of people's needs and preferences.

The care plans were personalised informing staff about people’s specific needs a

This inspection took place on 11 April 2017. It was unannounced.

Avenue House Nursing and Care Home provides a service for up to 45 older people, who may have a range of care needs, including dementia. There were 35 people living at the service on the day of the inspection.

We carried out an unannounced focused inspection of this service on 4 January 2017 and found that systems were in place to ensure people's daily medicines were managed in a safe way; however these had not always been followed adequately. New systems had been introduced to ensure medication was managed safely, including a change of pharmacy to supply medication to the service. However, the new systems for ordering medication had not yet been fully implemented, resulting in four people running out of prescribed medication prior to this inspection. This was a continued breach of the legal requirement to ensure people's medicines are managed so they receive them safely.

We carried out this inspection to check the progress with the improvements detailed in the action plan. This report only covers our findings in relation to these areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for 'Avenue House Nursing and Care Home' on our website at www.cqc.org.uk.

During this inspection we returned to see if the service had made the improvements we asked for and we found that the provider was now meeting this regulation.

The service did not have a registered manager. Since our last inspection, a new manager had been appointed who informed us they were going to apply to register with the CQC soon. They have since left the service and the provider is in the process of recruiting to the position of registered manager. In the interim, the service is being managed by a support 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.

Improvements had been made to the systems in place for recording, administering and storing medication. The provider had introduced improved systems for auditing medication and ensuring a robust overview of stock control and ordering new medication. The processes in place were more robust and more regular audit checks were taking place of all aspects of the medication systems, including recording and disposal. Issues were now identified and addressed in a more timely manner.

Although we found that improvements had been made during this inspection, more time and further work was needed to fully implement and embed required improvements. We have therefore not changed the rating for 'safe' on this occasion, because to do this would require consistent good practice over a sustained period of time. We plan to check these areas again during our next planned comprehensive inspection.

This inspection took place on 4 January 2017. It was unannounced.

Avenue House Nursing and Care Home provides a service for up to 45 older people, who may have a range of care needs, including dementia. There were 35 people living at the service on the day of the inspection.

We carried out an unannounced comprehensive inspection of this service on 5 October 2016 and found that two legal requirements had been breached. Systems were in place to ensure people’s daily medicines were managed in a safe way; however these had not been followed adequately on the day of the inspection. We found medication that had been missed, not given and one that had run out.

We also found that the provider had carried out appropriate checks on new staff to make sure they were suitable to work at the service. However, the checks for agency staff were not as robust. Although checks had been carried out by the supplying agency, there was no evidence to show that the provider had ensured these were satisfactory and agency staff were safe to work at the service.

After the inspection the registered manager submitted an action plan which outlined the improvements they planned to make to address these areas.

We carried out this inspection to check the progress with the improvements detailed in the action plan. This report only covers our findings in relation to these areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Avenue House Nursing and Care Home’ on our website at www.cqc.org.uk.

During this inspection, we found action had been taken to address the two previous breaches. However, further work was still required to ensure required improvements were made and fully effective.

After the October 2016 inspection, the registered manager informed us they were leaving the service. This meant there was not a registered manager in post at the time of this inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

A new manager had been appointed who assisted with this inspection. They informed us they were going to apply to register with the CQC soon.

New systems had been introduced to ensure medication was managed safely, including a change of pharmacy to supply medication to the service. However, the new systems for ordering medication had not yet been fully implemented, resulting in four people running out of prescribed medication prior to this inspection. This was a continued breach of the legal requirement to ensure people’s medicines are managed so they receive them safely. The manager had taken appropriate action and reported this to the relevant authorities. Although they were still in the process of investigating how the error had occurred, they shared their initial findings and described further changes they had started to implement to strengthen the systems relating to medication. This was to ensure people consistently received their medication on time and in a safe way in future.

Improvements were found in terms of safe recruitment checks for agency staff. We found that information was readily available for agency staff members working at the service, and there was no evidence that any of the agency staff were not safe to work there. However, we found anomalies in the detail of the information available for staff that had been provided by different agencies, making it difficult to know whether all legally required checks had been carried out prior to them working at the service. The new manager acknowledged our concerns and told us about additional work she planned to undertake with the agencies in question, to ensure the service was in receipt of the right information for all agency staff in future.

Altho

This inspection took place on 5 October 2016 and was unannounced.

Avenue House Nursing and Care Home provides a service for up to 45 older people, who may have a range of care needs, including dementia. There were 42 people using the service on the day of the inspection.

A registered manager was 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.

Systems were in place to ensure people’s daily medicines were managed in a safe way however, these had not been followed adequately on the day of the inspection. We found medication that had been missed, not given and one that had run out. The registered manager took immediate steps to address all of this and make people safe.

The provider had carried out appropriate checks on new staff to make sure they were suitable to work at the service. However, the checks for agency staff were not as robust. Although checks had been carried out by the supplying agency, there was no evidence to show that the provider had ensured these were satisfactory and agency staff were safe to work at the service.

Staff had been trained to recognise signs of potential abuse and keep people safe. People felt safe living at the service. Staff were confident about reporting any concerns they might have.

Processes were in place to manage identifiable risks within the service and ensure people did not have their freedom unnecessarily restricted.

There were sufficient numbers of staff who had the right skills and knowledge to meet people’s needs. Agency staff were being used to fill staff vacancies, but recruitment was underway and new staff had been appointed.

Staff had received training to carry out their roles, including support to complete nationally recognised induction and health and social care qualifications.

Systems were in place to ensure the service worked to the Mental Capacity Act 2005 key principles, which state that a person's capacity should always be assumed, and assessments of capacity must be undertaken where it is believed that a person cannot make decisions about their care and support. In general these processes were understood by staff and followed correctly.

People had a choice of food and they had enough to eat and drink. Assistance was provided to those who needed help with eating and drinking, in a discreet and helpful manner.

The service had developed positive working relationships with external healthcare professionals to ensure effective arrangements were in place to meet people’s healthcare needs.

Staff were motivated and provided care and support in a caring and meaningful way. They treated people with kindness and compassion and respected their privacy and dignity at all times.

We saw that people were given regular opportunities to express their views on the service they received and to be actively involved in making decisions about their care and support.

People’s social needs were provided for and they were given opportunities to participate in meaningful activities.

A complaints procedure had been developed to let people know how to raise concerns about the service if they needed to. People were confident in raising concerns if they needed to do so.

There was a registered manager in post who provided effective leadership at the service, and promoted a positive culture that was open and transparent. People and staff felt the registered manager was approachable and fair.

Systems were also in place to monitor the quality of the service provided and drive continuous improvement.

Avenue House Nursing and Care Home provides a service for up to 45 people, who may have a range of care needs including dementia. There were 35 people living in the home on the day of this inspection.

We carried out an unannounced comprehensive inspection of this service on 5 May 2015 and found that legal requirements had been breached. This was because the arrangements for managing PRN (as required) medication were not always safe. In addition, some equipment necessary to meet people's needs in an emergency, was missing. The provider sent us an action plan after the May inspection, setting out what they would do to meet legal requirements and address these concerns.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met the legal requirements. In addition, we looked at the staffing arrangements for the home, because prior to the inspection, we had received information which raised concerns about staffing levels.

This report only covers our findings in relation to these areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Avenue House Nursing and Care Home on our website at www.cqc.org.uk.

During this inspection on 6 January 2016, we found that improvements had been made.

After the May 2015 inspection, a new manager had registered with the Care Quality Commission to manage the service. Like registered providers, registered managers 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.

New systems had been introduced to ensure people using the service had their medicines managed in a safe way.

Regular checks were being made, to ensure equipment necessary to meet people’s needs in the event of an emergency, was being properly maintained.

We also found there were sufficient numbers of suitable staff to ensure peoples’ safety and meet their individual needs.

Although we found that the service was no longer in breach of legal requirements, we have not changed the rating for the service on this occasion, because to do this this would require consistent good practice over a sustained period of time. We therefore plan to check these areas again during our next planned comprehensive inspection.

This inspection took place on 5 May 2015 and was unannounced.

Avenue House Nursing and Care Home provides a service for up to 45 people, who may have a range of care needs including dementia. There were 38 people living in the home on the day of the inspection.

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. A new manager had been appointed shortly before this inspection however, who informed us they were in the process of applying for registration.

Systems were in place to ensure people’s daily medicines were managed in a safe way and that they got their medication when they needed it. However, we did find some anomalies in regard to PRN (as required medication).

We also found equipment necessary to meet people’s needs in the event of an injury or an emergency was not being properly checked and maintained.

Staff had been trained to recognise signs of potential abuse and keep people safe. People felt safe living at the service.

Processes were in place to manage identifiable risks within the service and ensure people did not have their freedom unnecessarily restricted.

There were sufficient numbers of staff who had the right skills and knowledge to meet people’s needs.

The provider carried out proper recruitment checks on new staff to make sure they were suitable to work at the service.

Staff had received training to carry out their roles, including support to achieve national health and social care qualifications.

We found that the service worked to the Mental Capacity Act 2005 key principles, which state that a person's capacity should always be assumed, and assessments of capacity must be undertaken where it is believed that a person cannot make decisions about their care and support.

People had enough to eat and drink. Assistance was provided to those who needed help with eating and drinking, in a discreet and helpful manner.

The service had developed positive working relationships with external healthcare professionals to ensure effective arrangements were in place to meet people’s healthcare needs.

Staff were motivated and provided care and support in a caring and meaningful way. They treated people with kindness and compassion and respected their privacy and dignity at all times.

We saw that people were given regular opportunities to express their views on the service they received and to be actively involved in making decisions about their care and support.

People’s social needs were provided for and they were given opportunities to participate in meaningful activities.

A complaints procedure had been developed to let people know how to raise concerns about the service if they needed to.

Systems were also in place to monitor the quality of the service provided and drive continuous improvement.

Our inspection looked at how the people who lived in the home were involved in decisions about their care and welfare at the home. We saw that the care plans for the people in the home were being updated to a new structure. The plans we saw were clear and up-to-date. However, we did note that the plans would benefit from clearer recording of discussions and decisions relating to Mental Capacity Act assessments and best interest decisions.

We talked to some of the people who lived at the home, family members who were visiting at the time of our visit and some of the care staff. The family members who spoke with us told us, “We are very happy. The home is clean and X is well cared for.”

Another person said, “X is safe, warm and well cared for. The staff are very pleasant.”

The staff we spoke with told us that they enjoyed their work, they told us, “It is very busy but I love what I do.”

We discussed safeguarding arrangements with the manager and care staff and found that the Provider had clear policy and procedures in place. Staff were aware of the arrangements should they need to identify any concerns.

We spoke with the nurse clinical lead about the management of medicines and we saw that arrangements were in place to monitor the administration of medicines. Finally, we saw that the home had suitable arrangements in place for dealing with information and records storage.

We found the new registered manager had recently taken responsibility for the home and had sought to bring about improvements in a number of areas.

We saw the staff approached their work in a caring and supportive manner. When we spoke with some members of staff they were able to explain their role to us and understood their responsibilities to ensure people were cared for appropriately and their needs were met.

People who lived at the home and family members who were visiting relatives told us they were happy with the care and support provided. A person who lived at the home told us, “They look after me here.”

One relative told us, “During the bad weather I was unable to get in (to the home), but I knew X was safe.” Another family member told us, “I know that X is warm, well fed and looked after.”

We carried out this compliance review to check that improvements had been made since our last review. During this recent inspection the required improvements had been made which included better organisation of meals.

We saw that people using the service and staff were more relaxed during the meal. There was space for staff to sit with people who needed help with their meal and talk with them and people told us that they were enjoying their lunch.

We saw that staff were using safe ways to assist people who were not able to walk unaided which reduced the risk of injury. People looked relaxed and comfortable in the presence of staff who were assisting them.

Five people we spoke with were happy with the care that they received and told us that they were treated with respect. People’s comments included;

“I get good care”, “Staff come when I need them”, “They are very good and will do anything for me”, “I get the help that I need”.

We spoke with two relatives who told us they were very happy with the care being provided to their mothers. One relative told us that at the time of admission the cook had involved them in discussions about how they were going to meet their mother’s special dietary needs.

We asked three people if they felt safe and if they had someone that they could talk to if they had any worries or were not treated properly. They all said that they felt safe and would speak to staff or a relative if they were worried.