Averlea Residential Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulations in relation to meeting the requirements of the Mental Capacity Act 2005 and management of the service.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

There was no system for formally reviewing falls regularly to help ensure any patterns or trends were identified. There was no recording of lessons learned from incidents to help mitigate the risk of reoccurrence.

However, staff told us they would report any accidents and incidents, and we saw incidents when people had fallen had been recorded. Some improvements had been made since our previous inspection. For example, systems for supporting staff such as regular training and supervisions were now established. An external professional commented; “I have no concerns towards the home and feel they have undertaken what was required from the previous inspection and have learnt from it. This has led to a better and organised service.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were processes to help ensure people’s information was shared appropriately with health and social care professionals. A GP conducted a ‘ward round’ and staff could access additional advice and guidance from the GP surgery if required. Hospital information sheets were available for use if people needed to be admitted into hospital. These provided an overview of people’s needs.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People were not supported in line with the requirements of the Mental Capacity Act 2005 (MCA). We found a restriction in place preventing people from leaving the service. The registered manager told us this was used to keep one person safe as they might attempt to leave without staff support. There was no reference to this in the person’s care plan. There were no Deprivation of Liberty Safeguards (DoLS) authorisations relating to this restriction. The registered manager submitted a DoLS application during the inspection but did not complete a mental capacity assessment beforehand to evidence the person was unable to consent to the restriction. They had not considered the impact of the restriction on other people living at Averlea. We were not assured there was a good understanding of the principles of the MCA and associated code of practice. The registered manager discussed the situation with the local DoLS team who offered guidance on how they should address the situation.

Staff had received training in safeguarding and told us they would report any concerns they had. They were confident these would be addressed internally but told us, if not, they knew how to report concerns to external agencies.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Potential risks to people’s health and well-being had been identified and risk assessments developed. These lacked detailed guidance for staff to follow in order to mitigate identified risk. Risk assessments sometimes covered more than one area which meant it was difficult to extract the relevant information. For example, one person had a risk assessment which identified risks for epilepsy, falls, breathing / chest, water retention (feet) and being unsteady on feet. The ‘action to be taken’ section did not refer to any actions. The ‘hazard outcome’ covered all areas briefly. All risks had been prioritised as medium. We were not assured each risk had been considered and prioritised separately.

However, external professionals told us they had no concerns about people’s safety and risks were well managed. One commented; “Staff have always appeared to be well informed with the risks that the service users face and are always prompt to respond with the appropriate action/equipment to minimise that risk; e.g. rushing to get the appropriate walking aid for a resident when he suddenly decided to stand and go for a walk.”

Personal Emergency Evacuation Plans (PEEPs) were now available for all residents.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Since our previous inspection, improvements had been made to the structure of the premises, including fire safety improvements. However, we found a door to the laundry which was marked ‘keep locked’ had been left unlocked. The room contained products which would pose a risk if ingested. Some pipes were exposed and hot to touch. Water temperature checks were not taking place. The registered manager immediately took action to address this.

Other environmental checks were completed. For example, external contractors had checked and serviced electrical equipment and completed a legionella test.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff had been safely recruited and appropriate checks completed before they started working at the service. There were now enough staff to respond to people’s requests for assistance. We observed staff were available to support and encourage people as they needed it. Call bells were answered quickly, and staff were patient in their approach. A member of staff commented; “It’s much better now there are always 3 of us on during the day.” One person told us; “Staff respond on time; they might get delayed if busy or when handing over shifts but they do their best.”

Since our previous inspection staff had completed training in all areas necessary for the service apart from supporting people with a learning disability and autistic people. Since 1 July 2022, all registered health and social care providers have been required to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people who have a learning disability.The registered manager told us the training was included in their schedule for the next year.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

A cleaner was employed, they had a regular schedule for cleaning bedrooms. The registered manager told us night staff cleaned communal areas, however, there was no schedule or check list to evidence this was completed. There was no schedule for deep cleaning any part of the service.

We found hair products, bath scrunchies and a prescribed pot of cream in a shared bathroom. Towels were stored on open shelves. This increased the chance of cross infection. The laundry floor was damaged and carpets throughout the building were badly stained and frayed. The registered manager told us they were planning to replace carpets throughout the building.

There was enough personal protective equipment (PPE) throughout the home for use when needed. Hand gel was available in the entrance hall for visitors to use.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People generally received their medicines as prescribed. However, there were no suitable checks of peoples’ medicines records. Improvements were needed to ensure the accurate completion of these records, and to keep other associated medicines records up to date. Protocols had been developed for medicines to be given ‘when required’, and times of administration were recorded. However, some medicines prescribed this way had no protocol available to guide staff on their appropriate use for that person. Records for medicines administered by a patch were not available for 1 person to show these were applied and rotated in a suitable way. Some charts had no allergy status recorded, and not all handwritten charts or amendments had been double checked and signed for accuracy.Medicines care plans lacked risk assessments or information for some medicines including blood thinning medication and flammable topical preparations, to show that people’s individual risks had been considered.

There was no suitable audit system to enable these issues to be identified and addressed.

People received their medicines in a safe way, staff took time to make sure they were taken properly. One person told us they were happy with the way they received their medicines, and they were always given on time.

There were suitable arrangements for ordering, storage and disposal of medicines, including those requiring extra security. Changes were made to the arrangements for any items needing cold storage during our site visit to ensure these were kept safely and securely.