Archived: Avens Court Nursing Home

Avens Court Nursing Home is a care home providing personal and nursing care to 51 people aged 65 and over, many of whom may be living with dementia. The home, which is in a converted house and is set over two floors, each floor having its own lounge area. At the time of our inspection, there were 29 people living at Avens Court.

People’s experience of using this service and what we found

People were not safe living at Avens Court. There was a lack of staff to meet their needs and instances of potential abuse were ignored by staff or not raised as such. People had accidents and incidents and staff did not take steps to help ensure future accidents or incidents were reduced.

Although risks to people were identified, staff did not follow guidance to help keep people free from harm. People were left at risk of pressure sores, malnutrition and falling due to staff not having sufficient time to supervise people or taking the time to care for people in the way they needed.

People’s medicines were not handled safely. There were numerous gaps in medicines records which meant the registered provider could not guarantee people received the medicines they should have. People also lived in an environment which put them at risk of infection. There was a lack of effort by staff to regularly bathe people and people were left in wet bedding due to staff shortages and the inability to meet people’s needs in a timely manner.

The management and leadership of the service was ineffective. The registered provider had failed to act in a transparent and open manner and also failed to address previous concerns. Despite staff and relatives raising concerns, the registered provider had not listened and made changes to improve the care for people and the service they received. Although the registered provider had engaged a management service for Avens Court they demonstrated a lack of candour as they had not informed people, relatives or staff.

Despite audits being carried out at the service, shortfalls were not identified or addressed. Organisation of staff was inadequate in that there was a lack of senior management at the service. This left inexperienced staff, who did not know people, running the service.

The registered provider did not meet their requirements of registration in that there had been a lack of registered manager in the service for nine months. They had also failed to report potential safeguarding concerns to CQC.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Requires Improvement (published 4 December 2019).

Why we inspected

Since our last inspection we received numerous concerns in relation to the management of the service, staffing levels, people’s needs not being met and a poor living environment in relation to cleanliness. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-Led sections of this full report. We found continued breaches of regulation in Regulations 12, 17 and 18 of the Health and Social Care Act 2008.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Avens Court Nursing Home on our website at www.cqc.org.uk.

The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of Inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as Inadequate for any of the five key questions it will no longer be in special measures.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress.

Avens Court Nursing Home is a care home providing personal and nursing care to 51 people aged 65 and over, many of whom may be living with dementia. The home, which is in a converted house and is set over two floors, each floor having its own lounge area. At the time of our inspection, there were 40 people living at Avens Court.

People’s experience of using this service and what we found

People told us they felt safe and well cared for and that staff were kind. However, our observations on the day were that people may not always be kept safe as staff did not always follow safe practices. We also found staff did not always demonstrate a respectful approach towards people. There was also evidence that people may not always receive care in line with their care plan. People’s care records lacked detail in some areas and were contradictory in others.

Although people were seen to be given their medicines, medicines practices were not robust and clinical staff did not always follow good practice.

People did not receive care when they wanted it due to a lack of a suitable number of staff deployed within the service. People were left without interaction for long periods of time as staff were too busy to spend time with people. Much of what we observed was task orientated care from staff.

Improvements had been made to the service since the registered provider had taken it over. People lived in an environment that was undergoing refurbishment. This would improve the décor and layout within the premises. There was an open and transparent approach with the Commission, the introduction of a better auditing process and better communication between the staff team and people and their relatives. Although some of the auditing had not picked up the shortfalls we identified at our inspection.

Staff had the opportunity to access a wider range of training as well as meet with their line manager to discuss their role and progress.

People had good access to healthcare professional involvement to help ensure they stayed well and people’s consent was sought in line with the legal requirements relating to the Mental Capacity Act 2005. This was because people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests.

Feedback was sought from relatives and was being used to start to improve the service.

We have found evidence that the provider needs to make improvement. Please see the Safe, Caring, Responsive and Well-Led key question sections of this full report. You can see what action we have asked the provider to take at the end of this full report. For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (report published 2 October 2018). Since this rating was awarded the registered provider has changed. We have used the previous rating to inform our planning and decisions about the rating at this inspection.

The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on our methodology of inspections.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.