Archived: Avon Lodge and Avon Lodge Annex

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We identified 2 continued breaches of regulations. Firstly, we found a continued breach in respect of the provision of safe care and treatment. Secondly, we found a continued breach in respect of good governance; the provider’s and manager’s oversight had not been sufficient or effective in addressing the breaches of regulations and the issues raised at the previous inspection. We identified a new breach of regulation in respect of the provider's failure to follow the ‘Right support, right care, right culture’ guidance. Processes were not in place to ensure that people's health and wellbeing was supported, that their independence was supported, and that people's future needs for care and support were reduced. People did not always receive evidence based care and treatment, and people were not supported to manage their health and wellbeing. Communication needs were not always fully explored. Systems in place did not always ensure compliance with the Mental Capacity Act.

This service scored 42 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was limited assessment of people's aims and aspirations. There were limited meaningful goals in place for people and people had limited plans in place to encourage and support them to gain independence. This meant people were not supported to lead as fulfilling and enriching lives as possible. This was not in line with the 'Right support, right care, right culture' guidance. People's communication needs had not always been fully explored. This meant people were not always fully supported to share their views and make choices.

Staff were involved in monthly care plan reviews. Leaders confirmed these assessments and reviews were carried out. However, staff had not identified the issues we found on inspection when assessing and reviewing people's needs.

The provider used recognised tools to assess people's needs, however, some assessments were not carried out consistently or accurately.

People's experience was that they did not always receive evidence based care and treatment. Weight management was not effective, and tools used in this regard were not used consistently or not used correctly. 2 hourly night time checks had been implemented for everyone using the service with no justification for this potentially disruptive and intrusive practice.

Staff and leaders had not identified the shortfalls in care, and they had failed to recognise instances where care fell short of best practice guidance.

Documentation did not always support that people's care was provided in compliance with the Mental Capacity Act. Quality assurance processes had not identified where care was provided which was not in line with evidence based best practice.

People were supported to access some healthcare professionals such as the GP or chiropodist when needed. However, people had not been supported to access dieticians or other appropriate professionals to assist and guide with weight related concerns and conditions. This impacted people's health and wellbeing.

Following the previous inspection, the service had been provided with significant support and input from various professionals. Despite this, satisfactory improvements had not been made.

Processes and systems were either not in place or not effective in robustly implementing recommendations from professionals to support improvements at the service. Processes had not identified areas where people would benefit from professional input and appropriate referrals had not been pursued.

People were not supported to manage their health and wellbeing. Appropriate actions had not been taken around weight management and nutrition related conditions. Some people were largely independent, but the service had not maximised this, for example, people were unable to do their own laundry due to the location of the equipment, and people did not assist with the shopping. One person was not included in the weekly house meeting.

Staff and leaders had failed to identify the issues around the management of people's health and wellbeing and therefore had not taken appropriate actions to manage this effectively.

Processes were not in place to ensure that people's health and wellbeing was supported, that their independence was supported, and that people's future needs for care and support were reduced.

People appeared settled and content, and told us things had improved following our previous inspection. However, this was due to the service no longer supporting some people whose needs they were unable to meet. We found people's health needs were not always monitored or managed appropriately, and there were limited goals and aims for people in place and limited meaningful measurements of outcomes for people.

Where staff had completed tools to monitor people's health, these were not completed consistently or correctly. This had not been identified by staff or leaders. Staff and leaders had not identified the lack of aims, goals and future aspirations recorded for people, and the lack of plans in place regarding working towards these.

The systems in place to monitor people's care and support, and to improve the quality of this, had not been effective. Some issues identified at the previous inspection had not been resolved. Outcomes for people were not robustly monitored. Plans were not always in place to improve people's quality of life, and tools used to monitor health and wellbeing were not always used or were not used correctly.

People and relatives did not raise any concerns around consent. However, restrictions were in place for 2 people and these restrictions were not supported by appropriate documentation. People were all placed on 2 hourly welfare checks during the night, with no evidence of justification for this or consent having been obtained.

Staff spoke about person-centred care and always giving people choice, discussing options with people and encouraging people to be independent. However, staff had not identified the shortfalls we found around compliance with the Mental Capacity Act.

Documentation around consent and compliance with the Mental Capacity Act was not always completed or completed correctly. The manager in post at the time of the inspection had received additional training in this area, however, this had not been effective as these errors and omissions had not been identified.