We carried out this unannounced inspection on 11 December 2018.

Avenue House is registered to provide care and accommodation for up to 21 older people who may be living with a diagnosis of dementia. On the day of the inspection there were 16 people living at the home. Avenue 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 our previous inspection in November 2017, we identified improvements were needed to the management of medicines and the deployment of staff. We rated the service as 'requires improvement' overall.

This inspection was to check that the provider was taking the necessary action to improve the quality of care to people. During this inspection we found that improvements had been made to the systems in place to manage people’s medicines. We also found staff were deployed more effectively at peak times to respond to people’s needs.

There was a registered manager who was in attendance throughout the inspection. 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.

People told us they felt safe living at the home. We saw staff understood how to recognise and report harm or abuse. Risks to people’s safety were managed. There were some staff vacancies but sufficient staff were available to meet people’s needs. Arrangements to manage people’s medicines had improved. The home environment was kept clean and hygienic.

People’s needs were assessed to ensure these could be met. Staff had relevant training to help them meet people’s needs effectively. Staff sought people’s consent and people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People had access to facilities that met their physical needs but further consideration of signage to support people with dementia was needed. People’s nutritional needs were met and they were offered choices of meals. People had access to health care professionals when they needed this.

People described staff as caring and kind and said they were respectful. Staff protected people’s privacy and dignity.

People were involved in deciding their care and this was responsive to people’s specific needs. People had access to activities and there were some positive examples of contact time improving people’s well-being. People felt happy to approach staff with any concerns or complaints. People’s end of life needs was being considered to ensure they had appropriate professional support and that their wishes are known.

People were happy at the way the home was run. There had been a turnover of staff and the registered manager was working to recruit to vacancies. The registered manager had systems in place to check the quality of the service and was aware where improvements were needed such as staff supervision. People's feedback was sought but improvement in capturing this was needed. The provider worked in conjunction with other agencies to provide people with effective care.

We carried out this inspection on 25 and 30 August 2017 and it was unannounced.

Avenue House is registered to provide care and accommodation for up to 21 older people who

may or may not be living with a diagnosis of dementia. On the day of the inspection there were 15 people living at the home.

We carried out an unannounced comprehensive inspection of this service on 28 and 29 November 2016. At that inspection, we rated the service as ‘good’ overall. After that inspection we were notified of an incident in the home which resulted in a serious injury to a person living at the home. Information shared with CQC about the incident indicated potential concerns about the management of risk of falls and staffing levels. We also received some concerns in relation to poor care, lack of choice and staff working long hours. As a result we undertook an unannounced comprehensive inspection.

There was 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.

People told us that they felt safe in the home. They were supported by staff who were aware of the risks to them on a daily basis, how to support them appropriately and keep them safe from harm. Staff had received training in how to safeguard people from abuse and were aware of their responsibilities to report any concerns they may have.

Medicine audits had not identified some errors that had been noted on inspection and systems were not in place to ensure that some medicines had been stored safely. There were no protocols in place for ‘as and when required’ medicines which could mean these medicines could be administered inconsistently.

We received mixed responses with regard to the staffing levels at the home. Not everyone felt there were enough staff to meet people’s needs in a timely manner and the poor allocation of staff at lunch impacted on people’s lunchtime experience. Staffing levels were based on people’s dependency levels and staff worked to cover vacant shifts whilst staff recruitment was ongoing.

People were supported by staff who benefitted from an induction and training that provided them with the skills and knowledge to support people safely and effectively.

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

People’s human rights were respected by staff because staff applied the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards in their work practice.

People were offered choices at mealtimes and where assistance with eating their meals was required, this was done respectfully.

Staff were aware of people’s healthcare needs and requirements. People were supported to access a variety of healthcare services such as the GP, optician, dentist and dietician, in order to maintain good health.

People described the staff who supported them as ‘kind’ and ‘caring’. People were supported to make their own decisions on a daily basis by staff who respected their wishes. People were treated with dignity and respect.

People and staff were complimentary about the registered manager and considered the service to be well led. Staff felt supported and able to approach the registered manager with any concerns they may have, confident they would be listened to and any issues acted upon. There were a number of audits in place to assess the quality of the service, but not all issues highlighted on inspection had been identified by the home’s own audits. Requirements at the last inspection to introduce protocols for ‘as required medicines had not been completed.

The inspection of this service took place on 28 and 29 November 2016 and was unannounced

There was a registered manager in post and they were present at the time of the inspection. A registered manager is a person who has 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.

People were supported by staff who knew how to keep them safe and free from the risk of harm. Staff could recognise problems or potential signs of abuse and would be confident to report concerns. Risks were assessed and managed safely and sensitively.

People were supported by sufficient staff to meet their needs safely and effectively. People received support promptly and when requested. Staff were recruited safely meaning that only people suitable to work in the role were appointed.

We found improvements had been made in the management of medicines. People now received their medicines safety. This is because the registered manager had introduced safe systems for administering, storing and recording medicines.

People were supported by staff who were gaining in confidence and developing their skills in order to provide effective support. Training opportunities for staff were improving to enable this to happen. Staff felt well supported by the registered manager and their colleagues. Staff understood their roles and responsibilities to ensure people’s needs were met.

People’s rights were protected under the Mental Capacity Act 2005. The registered manager was aware of their responsibilities under this legislation and training for staff had been planned to enhance their understanding of this in practice. Staff did however ensure people were offered choices and were involved in decision making as far as they were able.

People enjoyed meals which met their dietary needs. They had sufficient to eat and drink. People’s individual preferences and cultural needs were catered for. Staff knew how to ensure people’s medical conditions were not affected by their diet. Staff worked with healthcare professionals when required to ensure people’s continued good health and wellbeing. This joint working ensured people’s needs were met consistently and effectively.

People were supported by staff who were kind and caring. Staff were friendly and listened to people. This enabled staff to meet people’s needs in ways that they preferred. People felt in control of how they were supported. People’s independence was promoted wherever possible. People’s privacy and dignity was respected and staff understood the importance of this.

People received a responsive service and staff accommodated people’s changing needs and wishes. People did not currently have access to structured activities although this was an area where improvement had been identified.

People told us they were able to raise concerns and felt these would be acted on by the registered manager. The provider had a system to deal with any complaints. People were regularly asked if they were happy with the service provided. There were systems in place to ensure that people’s views and opinions were heard and their wishes acted upon.

The registered manager provided effective leadership. Improvements had been made within the home since our last inspection. This meant people now received a better quality of care and support. People felt involved and consulted in the running of the home, as did the staff team. There were systems in place to monitor the quality of the service provided. Surveys, questionnaires and audits all reflected that the service was improving and this was having a positive impact on the people who lived at the home. Further improvements, especially in relation to the environment had been identified and timescales for achievement identified.

The inspection was carried out so we could answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with six people using the service, three relatives, the members of staff supporting people and records relating to people’s care and the running of the service.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

Some people told us they felt safe and staff we spoke with had some awareness of safeguarding procedures, and how this would help them protect people they supported. The provider did tell us they did not have a copy of the local multi-agency safeguarding adult’s procedures. This meant that staff may not have access to current information on safeguarding.

We had concerns that the provider and staff may not have learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This was because the provider was not able to demonstrate how they would routinely identify and assess the service and put systems in place to minimise risks. This meant that the risk of harm to people may not always be identified, or lessons learned from mistakes.

There were no apparent risks present when we looked around the home and we found the environment was visually clean. People we spoke with told us staff took steps to ensure people’s hygiene was promoted and they were satisfied with the cleanliness of the building. We saw some audits where actions needed were identified, for example in respect of infection control and medication, but there was no written response by the provider as to when and how these would be addressed.

We asked staff about their understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). This legislation makes provision for persons who lack capacity, and how decisions should be made in their best interests. Staff did not fully understand this legislation they had not received any training about it. This meant that where people did not have the capacity to consent, staff may not fully understand the legal requirements of the MCA or DoLS.

We saw some care records signed by people or their representatives, but there was a lack of assessment in respect of people’s capacity in some instances. Records did not show whether the person had capacity and could have given their own consent to bedrails. This meant the provider had not checked if the person had capacity to give consent themselves or opposed to their relative.

Staff training records were not available. As a result the provider was unable to tell us of training staff may need. Staff told us they received training in mandatory areas and showed a reasonable knowledge of how to maintain people’s safety, but the last infection control audit had shown training in infection control was overdue. There may have been other training staff may need to ensure they are up to date with how to do their jobs safely that was not identified.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to putting a system in place to assess and monitor the quality of service and keep people safe.

Is the service effective?

People’s health and care needs were not always assessed with them or their relatives. People told us they were not always involved in writing their care plans. Some people were not aware of what was in their care plan, although were unconcerned as they said they received the care they wanted. One visitor said their relative’s, “Care plan was not discussed with me initially, although staff ran a few things past me”. Care plans did not always identify people’s health and care needs. We found information staff told us about risks to people’s health was accurate. We found there was a lack of information in some people’s records about risks to their health, for example people assessed at high risk of sore skin or with diabetes. People did tell us that staff met their needs though. This meant that information was not always available to staff to allow them to offer support consistently to meet people’s needs.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring people’s care records reflect their current needs and assessments are updated frequently enough to ensure they are accurate.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people, and showed they were aware of people’s preferences. People commented, saying staff, “Are wonderful” and “I like it here”.

We were told by a relative that they had completed a satisfaction survey. They said they had raised some concerns but have not received feedback. The provider was unaware of issues they had raised so was unable to tell us what action they had taken to address them. Some people told us they were confident that matters would be dealt with if they complained to staff, others said they were not. We found that the home’s complaints procedure was not on display in the home. Staff said they would only provide this to people on request. This meant people may not always be encouraged to share their views, and there was a risk of their concerns and needs not properly being taken into account.

People’s preferences, interests, aspirations and diverse needs were not always recorded, although care and support was provided in accordance with people’s wishes. People were positive about food choices and we saw that staff were attentive when supporting people with their meals. One person told us, “Food is good and wholesome; they are well presented, and often have a chat with the cook”.

We asked the provider to tell us what they are going to do to meet the requirements of the law in relation to involving people in the running of the home, and helping them share their views on the quality of the service.

Is the service responsive?

We looked at how the service worked with other health care professionals to ensure people’s health care needs were addressed. People told us that staff responded to people’s changing health needs to ensure appropriate health professionals were involved as and when needed. We found some care plans did not always reflect advice from health professionals about people’s changing needs. This meant there was a risk staff may not be aware of important information about people’s changing needs.

Is the service well-led?

This report states that the registered manager is Mrs M Grosvenor who was not managing regulatory activities at this location at the time of the inspection. Their name appears because they were still identified as a registered manager on our register at the time.

Staff we spoke with said that if they witnessed poor practice they would report their concerns but were no longer supported by a registered manager. The provider told us that they had interviewed prospective candidates for the manager’s post.

The service did not have a robust quality assurance system. The shortfalls identified by us at our previous inspection had not been addressed. We found issues of concern during this inspection and the provider could not evidence they had responded to issues they had identified. This meant that issues of concern were not routinely identified and responded to by the provider through continuous monitoring of the service.

We have asked the provider to tell us what they are going to do to meet the requirements of the law so they are able to learn from their assessment and monitoring of the service.

We inspected the home in October 2012 and found that there were two areas where the provider was not meeting essential standards of quality and safety. We carried out this inspection to see what improvements had been made in these areas and to monitor compliance against other standards.

We spoke with six people that lived at the home, one visitor, three staff and the deputy manager during our inspection. As some people were not able to clearly express their views we observed how people were cared for by staff.

We saw staff engaged positively with people. We saw that staff were readily available and responsive to people’s requests for assistance. People told us that, “You ask for anything and you get it” and, “Service second to none”. People said the care they received reflected their needs and choices and that staff had asked them what they thought was important.

We saw people were protected against the risks associated with medicines and there were appropriate arrangements in place to manage these.

We saw that there was an improvement in the systems for assessment and monitoring of the quality of service that people received with people’s views sought as part of these.

Staff we spoke with had a good awareness of people's needs, this not always reflected in people's care records. This meant that less experienced staff may not have access to information about people's needs.

We spoke with three people that lived at the home, three visitors, three staff, the manager and provider during our inspection.

We saw staff engaged positively with people and promoted people’s privacy and dignity. People said the care they received reflected their care plans. Visitors confirmed they had been involved in their relative’s care.This meant that people or their representatives were given appropriate information and involved in planning their care.

People’s needs were assessed and their care and treatment was planned and delivered in line with their care plan. People told us they were happy with the care they received at the home, one telling us, “Able to approach people to talk it out if have a problem and rectify it if it is”. Visitors told us they were satisfied with the service and the manager listens to and resolves any issues raised.

The environment was adequately maintained. One person told us that they had, “A comfortable little room”, another saying their , “Room is lovely, very nice”.

Records relating to staff employed did not always show how the provider protected people.

The provider did not have effective systems in place that identified, assessed and managed all risks to the health, safety and welfare of people who used the service and others, but said they were looking to develop these.

People we spoke with told us about their support needs and said that these are met by the staff at the home. At the time of our last review in May 2011 people told us that they were unaware of their care plans (written information as to what care and support staff provide to people). The support they told us they were provided and needed was recorded in those we saw.

We heard from people that staff are learning key words in other languages so as to assist communication and understanding with some people living at the home.

We spoke with people about their views of the foods available to them and they told us that the dinners have improved a lot “Much better”, “fish is beautiful”, “nice mixed grill yesterday” and “lovely stews”. One person told us that “Talk to the cook about what is available and she is always willing to do something different to the menu”.

We heard that there were occasional issues with the food but these were sorted out when mentioned and it was noticeable that the meat has improved since the home has started using a new butcher.

People told us that there were always at least two choices available for every meal, although there were more choices at tea time when the manager was on duty. We also heard that people are informed of changes to the menu in meetings with the manager.

People we talked to told us that that they “definitely” feel safe at the home and know how to raise concerns when they have any. One person said to us that they felt there were able to share their thoughts without any fear of victimisation.

People told us they can self medicate if they wish although no-one currently chooses too. We heard that staff give medication to people as is needed, and people consent to the staff handling their medication for them.

Our inspection took place on 6 and 7 August 2015 and was unannounced. We last inspected the service on 9 April 2014 and found that the provider was not meeting the law in respect of ensuring there was sufficient staff available to meet people’s needs and people’s consent to care was not consistently sought. In addition there was no system in place to ensure the quality of the service was managed. After the inspection, the provider wrote to us and told us how they were going to make improvements to ensure these matters were addressed. During this inspection we found the provider had made some improvements to the service.

Avenue House is a care home that provides care and accommodation for up to 21 older people who may have dementia.

The service did not have a registered manager at the time of our inspection, although the manager has since registered with the Care Quality Commission (CQC). 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.

People told us they felt safe at the service. Staff were knowledgeable as to how to escalate any allegations of abuse although there had been one occasion where an incident had not been escalated in accordance with local safeguarding procedures. The incident was reported after our inspection.

People told us they received their medicines when needed although systems for the management of medicines were not always robust enough to identify where people may not have received their medicines as prescribed, or that medicine records were always accurate. Other risks to people’s individual health and safety were assessed and we saw action was taken by staff to minimise risks for example, where people were at risk of weight loss appropriate action was taken.

The provider had recruited additional staff since our previous inspection so they could ensure safe staffing levels could be maintained. People told us that there were sufficient staff available to meet their needs.

People told us, and we saw care and support was provided at the time of the inspection in a way that showed staff were caring. Staff were knowledgeable about people’s care and support needs, and were supported with appropriate training, although the staff awareness of caring for people living with diabetes could be improved.

People told us there were supported by staff to make decisions about their day to day care and staff understood how to promote people’s rights and work in their best interests. People’s healthcare needs were promoted and regular appointments with healthcare professionals were maintained.

People told us they enjoyed the foods that were available and had enough to drink. People who were identified as having a preference for specific cultural meals did not have these provided by the service, with provision of these by relatives.

People told us that they felt well cared for and said staff understood what was important to them. They told us the way care and support was provided reflected their individual wishes. Staff had a good knowledge of what was important for people.

People had access to planned activities and told us they were happy with how they spent their time. Relatives told us stimulation for people could be improved and their views were shared with the manager during the inspection, who made a commitment to respond to these.

People knew who to speak with if they had any concerns and felt staff listened to them.

The provider had introduced a system for monitoring the quality of the service. However, there was still scope to develop this further to so that risks were consistently identified and areas for improvement were identified and acted upon. People we spoke with were happy with the quality of the service they received although some relatives told us of areas that could be better and some were not always fully confident that these would be addressed. People and staff told us they found the manager and other senior staff approachable and were able to share their views about the service with them.