Two inspectors carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?Avonwood Manor was being operated by Healthcare Management Solutions, a management company that had been appointed when the service went into administration. The registered manager had resigned and was not present at the inspection.
There were 35 people living at Avonwood Manor on the day of our inspection. We spoke with 14 people, two relatives, the temporary manager, the deputy manager and six staff.
Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.
If you want to see the evidence that supports our summary please read the full report.
This is a summary of what we found:
Is the service safe?
We found that overall the service was not consistently safe and some improvements were required. This was because the risks to people had not been consistently assessed and plans were not in place to minimise any risks. For example, in relation to any behaviour that challenged others. We found the home needed to make improvements in this area. We have told the provider to take action about these concerns.
People we spoke with told us they felt safe at the home. We observed people were relaxed with staff and freely approached staff.
There were enough staff to meet people's needs during the inspection and the temporary manager had assessed the staffing levels.
People were protected by the monitoring of prevention and control of infection.
We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards. The temporary manager was reviewing whether any applications needed to be made in response to the Supreme Court judgement in relation to Deprivation of Liberty Safeguards.
Is the service effective?
The service was not effectively meeting the needs of some of the people who used the service.
People's care plans did not always include all of their care and treatment needs so that staff knew how to care for them. We found the home needed to make improvements in this area. We have told the provider to take action about these concerns.
People received appropriate support from healthcare professionals when required.
People were protected from the risks associated with nutrition and hydration. People were not given visual or verbal choices of meals. This meant that people who were living with dementia were not given a choice of food when it was given to them.
Staff had not been trained in dementia care and did not have the skills and knowledge to be able to meet the needs of people living with dementia. There were plans in place to provide this training to staff.
Is the service caring?
We found the service was caring as people were treated with dignity and respect.
People spoke positively about the care they received and that staff were kind, caring and compassionate. One person told us: 'They treat me very well both the females and the males'.
People's privacy and dignity was always maintained. This was because staff respected people's privacy by respecting their private spaces and maintaining their dignity during personal care.
We saw that staff were kind and caring in their approach with people.
There was limited information about people's personal preferences, life history and lifestyle choices. This meant that staff did not have all the information to be able to care for and support people as individuals.
Some of the staff knew people well as they had worked at the home for a while and they knew their personal and nursing care needs and some personal information about them.
Is the service responsive?
People did not always receive a service that was responsive to their needs.
People's needs were not fully assessed and planned for. We found people received care that met their physical needs although we found there was limited support in place to meet people's emotional and social needs. We found the home needed to make improvements in this area. We have told the provider to take action about these concerns.
People had access to call bells and they were answered promptly. People who were not able to use call bells were checked frequently.
Staff responded quickly when people needed support and anticipated people's needs.
Is the service well-led?
The home had a registered manager who had resigned and they were not present at the inspection. Healthcare Management Solutions, the management company appointed had appointed a temporary manager.
Observations and feedback from people and staff was that the culture of the home was improving and becoming more open and transparent. This was because people and staff said they felt listened to by the temporary manager. A staff member told us: 'We are moving forward'.
We saw there were systems in place for reviewing and monitoring incidents, accidents, safeguarding alerts, concerns and complaints. These systems had identified the shortfall we identified during the inspection.
We saw that risks at all levels were anticipated, identified and there were plans in place to manage these risks.