Park Avenue Care Centre is a care home for older people, some of whom are living with dementia. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Park Avenue Care Centre is registered to accommodate up to 45 people. There were 39 people living at the home when we visited.

This inspection took place on 6 and 17 September 2018 and was unannounced. The last inspection of the service took place 29 August 2017 where we found three breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. These related to the management of risks to people, staffing levels; and quality monitoring systems. Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective, caring and well-led to at least good. The provider sent us an action plan on how they would improve. At this inspection, we found that the service had made improvements we identified at our last inspection but we found other areas that required improvement. This is therefore the second time the service was rated as requires improvement.

There was no registered manager in post. 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 about how the service is run.

At this inspection we found that the culture of the service was not always open. People, relatives and staff told us they were not kept informed and updated with what was happening at the service. There had been a high turnover of managers. Staff told us changes in the management team had affected their motivation.

There were limited activities taking place for people to participate in to relax and occupy them. There was no activities coordinator to plan and organise activities. People received the care they needed in a safe way. However, there were mixed comments about staffing levels. The provider was reassessing the level of staffing required for the service at the time of the inspection.

People received their medicines in line with their prescription. Medicines were managed and stored securely to ensure they were safe. Risk assessments identified issues that could pose risks to people’s health and safety, and management plans were in place to promote people’s health and well-being.

The environment was safe and well maintained. Health and safety checks took place regularly. Infection control practices were safe. The home was suitable and had appropriate facilities for people to use.

People were safeguarded from the risk of abuse and improper treatment. Staff had received training on safeguarding and they were knowledgeable on the procedure to follow if they had any concerns. Staff knew the procedure to follow to respond to emergency situations and events. Recruitment practices were safe. Applicants underwent checks before they were allowed to work at the service. Actions were taken to ensure learning from incidents. Actions were shared with staff through handover meetings and care plan updates.

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 supported this practice. People gave consent to the care and support they received. The manager and staff understood their responsibilities under the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

People’s needs were assessed following best practice guidelines. People’s nutritional needs were met. People were supported to eat and drink as required. They

Park Avenue Care Centre provides care and accommodation for up to 51 older people living with dementia. At the time of our inspection, there were 49 people using the service.

We undertook this unannounced inspection on 25 August 2017 Park Avenue Care Centre due to concerns raised relating to the way the service managed and responded to incidents. We carried out a responsive comprehensive inspection to check that people were safe at the service.

The service was last inspected in July 2016 and was rated Good. At this inspection we found three breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have rated the service requires improvement.

There was 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.

Risks to people were not always adequately managed to keep people safe. Risk assessments were carried out and identified risk of harm to people and management plans put in place. However, management plans were not comprehensive in all areas of risk identified to ensure people were protected from avoidable harm associated with them. Staff were not deployed properly to meet the individual needs of people in a way that kept them safe.

Regular spot checks and audits took place to identify any shortfalls in the service. However, we found these did not always detect areas that needed improvements.

Record of incidents and accidents was maintained. These were reviewed by the registered manager but we found that patterns and trends were not always identified and lessons learned from them to improve the service.

Recruitment procedures were robust and ensured only suitable personnel worked with vulnerable people. People’s medicines were managed in a safe way. Only qualified nurses administered medicines to people. The recording, storage, and disposal of unused medicines were effective and done in line with good practice. Staff understood how to recognise signs of abuse and how to protect people from the risk of abuse. The registered manager took actions to respond to allegation of abuse in line with organisation’s procedure.

Staff understood their responsibilities within the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People consented to their care and support. Staff were supported through induction, supervision; appraisal and training to enable them to effectively meet people’s needs. People were supported to eat and drink appropriately and to meet their dietary and nutritional requirements. The service liaised with relevant professionals to ensure people received appropriate support and care that met their needs.

Staff were kind and compassionate to people. People told us staff treated them with kindness and respected their dignity. Staff knew people well and understood their needs and preferences and told us they were cared for as they wanted. People using the service and their relatives were involved in their care planning and these were reviewed and updated regularly to reflect people’s current needs and circumstances. Staff encouraged and supported people to maintain the relationships which mattered to them.

People were supported in line with their wishes at the last stages of their lives. People’s Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) status was up to date and known to staff. The home had been awarded the ‘Platinum’ status with The National Gold Standards Framework Centre in End of Life Care for the high quality care they provide.

People were engaged in activities they enjoyed to occupy them and enable them to relax and socialise. People who were unable to join in group activities received individual based activities.

People

We carried out an unannounced comprehensive inspection of this service on 15 and 16 March 2016. A breach of legal requirements was found. This was because arrangements for people who may not have capacity to make decisions did not always follow legal requirements.

After the comprehensive inspection, the provider sent us an action plan to say what they would do to meet legal requirements in relation to this breach. They told us they would complete the action required by 17 June 2016. We undertook an unannounced focused inspection on the 20 July 2016 to check that they had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to the focused inspection for one part of the key question is the service effective? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Park Avenue’ on our website at www.cqc.org.uk.

Park Avenue Care Centre provides care and accommodation for up to 51 older people living with dementia who may have nursing, care and support needs. At the time of this inspection there were 47 people using the service. There was a registered manager in place. 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 understood their responsibilities as a registered manager and notified CQC appropriately of significant events.

At this inspection we found that processes were in place to follow the Mental Capacity Act (MCA) Code of Practice. People’s records confirmed their capacity to consent to separate decisions was considered when they were admitted to the home and this was reviewed regularly. Where people had capacity their consent had been sought in relation to possible restrictions for their safety such as the use of bed rails to reduce the risk of falls. Where people were assessed as unable to make a particular decision records demonstrated decisions were made in their best interests. There were copies of power of attorney records kept so that staff understood who might need to be involved or consulted in making best interests decisions.

In view of the changes made and the fact there were no other breaches or concerns in this key question at our last inspection we have revised the rating for this key question; to improve the rating to ‘Good’. The overall rating for the service remains the same which is Good.

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This inspection took place on 15 and 16 March 2016 and was unannounced. At the last inspection of the service on 25 March 2014 the provider was meeting all regulatory requirements inspected.

Park Avenue Care Centre provides care and accommodation for up to 51 older people living with dementia who may have nursing, care and support needs. At the time of this inspection there were 45 people using the service.

There was no registered manager in place. The previous registered manager had left the service in January 2016 and a new business manager had been appointed who was in the process of applying to become the 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 were asked for their consent before they were provided with care or support. People’s capacity to make decisions was assessed in line with guidance and the law. Applications for Deprivation of Liberty Safeguards authorisations had been appropriately made in line with current guidance. However, there was a breach of regulation as records in respect of decision making, where people may lack capacity to decide for themselves, were not always fully completed. You can see the action we have asked the provider to take at the back of the full version of this report.

People and their relatives told us staff were very caring, kind and gentle. We observed enthusiastic staff that were sensitively focussed on people’s individual needs. Professionals commented on the distinctive caring ethos and that staff seemed to enjoy their work. The service used person centred dementia specific approaches on a daily basis to increase people’s well-being. People were not rushed and their privacy and dignity was respected. The home was awarded commend status on a recognised framework for end of life care and their end of life care was sensitively and appropriately managed.

People and their relatives told us they felt safe at the service. Staff understood signs of abuse or neglect and knew how to report concerns. Individual risks to people were identified and monitored.

There were processes in place to manage emergencies. The premises and equipment including emergency equipment were routinely checked and maintained. Robust recruitment checks were in place before staff started work to reduce the risk of unsuitable staff being employed. Medicines were safely managed. There were enough suitably qualified staff to meet people’s needs. We observed that no one was waiting for care and support throughout the day and call bells were answered promptly.

Staff received regular supervision, appraisal and suitable training across a range of areas and told us they felt supported to enable them to carry out their role.

People had plenty to eat and drink and were encouraged to be independent or supported where needed at their own pace. People at risk of malnutrition or dehydration were monitored and their weight checked regularly. The home worked with a wide range of health and social care professionals to meet their health needs.

People’s needs were assessed to ensure they could be safely met. Care and support was planned to meet their individualised needs. There was a regular activities programme, which had been recently extended to include a wider range of opportunities for stimulation and interaction. Further improvements in the range of activities offered were in the process of being introduced.

People, their relatives and staff and health professionals all told us the service was well led. The management team looked for ways to constantly improve the service. The views of people at the service, relatives, staff and visiting professionals were sought and used to make improvements. Complain

We observed staff interacting with people using the service in a caring way. People told us they were happy living in the home and had no concerns with regard to their care. One person told us “staff are friendly. They always ask me what I want then do it”. A relative told us “I cannot fault the care provided. Staff involve me in the decisions related to the care of my husband”.

We found the provider had made suitable improvements to ensure that staff acted in accordance with legal requirements when carrying out mental capacity assessments for people who did not have the capacity to consent.

People using the service and relatives we spoke with were complimentary and satisfied with the treatment and care the home provided. For example, one person told us; “I do my hobby (embroidery) anytime. I get up when I feel like it and go to bed when I want to.” Another person described the home as “a hotel with nursing. I can have clean sheets every day if I want”. Three relatives we spoke with told us staff were caring and involved them in the care planning process of their relation. We found the atmosphere in the home calm and peaceful with people using the service visibly relaxed and engaged in a variety of activities. We observed people receiving personalised sensory stimulation such as hand massages, relaxing music, and aromatherapy as part of the Namaste programme.

We found people’s needs were adequately assessed and people received care that was planned for them. The provider had suitable arrangements in place to ensure the safety, availability and suitability of equipment that people and staff used. We saw that effective recruitment procedures were implemented to ensure competent staff where employed to meet the needs of people using the service. Appropriate records were maintained and securely stored to ensure people received safe care. However, we found the provider did not always complete mental capacity assessments in accordance with the legal requirements of the Mental Capacity Act (2005).

The inspection team was led by a CQC inspector and included an expert by experience, that means a person who had experience of caring for a person who has used services. This enabled the person using the service’s perspective to be reflected.

People who used the service and their relatives told us during our visit on 7 September 2011 that the treatment and care provided reflected individuals’ preferences, choices and life histories. They said that the staffing level was adequate and that people improved on coming to live at Park Avenue Care Centre. They said that staff respected people’s privacy and dignity and that people were kept safe at the home. And while they were not aware of any independent advocacy services, they told us that staff were approachable, and that they felt able to discuss with them any concerns, or changes or improvements needed.

Comments from people using the service included 'as good as you'll get', 'a good place', 'they do very well' and 'I'm happy'. One person described the home as 'a very nice place' and told us 'I feel jolly lucky and very happy'. Feedback about the staff included 'excellent service, I can find no fault with the staff', 'the staff are very good here' and 'the staff are kind'.

Feedback from family members or carers included 'I cannot praise this place enough - I know they are in good hands', 'It's a well run home', 'we are always made welcome' and 'we are very happy'.

We saw the home was part of the Namaste Care programme designed to improve the quality of life for people with dementia. Family members or carers commented positively about the activities now being provided on all floors and staff told us that this had made a 'big difference' to the care being provided particularly for individuals living with more advanced dementia.

Staff spoken to said that there were enough people on duty to meet people's needs and told us that they received the training and support they required to do their job.