The inspection took place on 13 and 14 November 2018 and was unannounced.

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

We inspected Averill House on 12 and 13 September 2017. The inspection was unannounced. The service was last inspected in February 2016, and rated Requires Improvement. There were three breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014, relating to person centred care, safe care and treatment, and staff training. Following the inspection the provider sent us an action plan which stated the breaches would be addressed. The service had produced an action plan and at this inspection we found significant improvements in all areas.

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

This inspection took place on 10 and 11 February 2016. The first day was unannounced, which meant the service did not know in advance when we were coming.

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 che

This inspection was limited in scope to looking at two areas where we had found non-compliance with regulations at the previous inspection on 28 April 2014.

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.

One inspector carried out this inspection. On the day of our visit the registered manager was on leave and we spoke with a relief manager. We talked with other staff and we observed care being given. We also looked at care records and other files. After the inspection visit we received further information and documents that we requested.

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.

We used a number of different methods to help us understand the experiences of people using the service. This was because many of the people using the service had dementia type illnesses which meant they were not able to tell us their experiences. We were able to speak with a small number of people who lived in the home. One of these people told us: "I'm happy enough". Another person said: "I could be a lot worse than be in here". A third person said: "They look after me". We spoke with one relative of someone who lived at the home. They said; "It's first class...They've been very good to me...[My relative] is very well looked after and has put on weight".

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

We used a number of different methods to help us understand the experiences of people

using the service. This was because many of the people using the service had dementia type illnesses which meant they were not able to tell us their experiences. We were able to speak with one person who used the service who told us: "Everybody's been good to me". We spoke to the relatives of two people, who used the home for respite care. Both were generally happy with the care their relatives received. This was summed up by one who said "I looked at lots of homes and this one seemed the best. I am very happy with the care".