Avon House

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff were consistently reporting incidents and accidents. Staff described an open culture where they felt able to raise concerns and discuss incidents. One staff member said, “There’s not a blame culture here, if a mistake is made you can say so and discuss what went wrong, that makes it a safer place for everyone.”

The registered manager and deputy manager had oversight of all incidents and reviewed events to ensure appropriate actions had been taken and to identify any learning. For example, the registered manager explained how they had noticed an increase in incidents that occurred between 5 and 6.30pm. They decided to change the deployment of staff at that time to ensure people were receiving the support they needed. This change had led to a reduction in incidents.

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.

Before admission to Avon House assessments were completed to ensure the service could meet people’s needs. The registered manager described how they worked with health and social care professionals to ensure safe care, for example when people were transferred from hospital. A relative confirmed they were involved in this process, they told us, “They (staff) visited Dad in hospital and assessed him there. We were kept informed.” Another relative told us, “The staff communicate with us very well.”

Staff explained how training was provided to ensure they could meet people’s individual needs, for example, staff had completed training in stoma care to be able to meet a person’s needs. A stoma is an opening made through the abdominal wall and connects the bowel to the surface of the tummy. Staff had received training in how to ensure any issues with the stoma were identified and managed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe living at Avon House and spoke highly of the staff who they described as kind and caring. One person described staff as being very patient and caring. They said, “I have never seen anything worrying, the staff are always kind and polite to people.”

Systems were effective in identifying safeguarding issues and appropriate referrals had been made. Staff had received training in safeguarding and demonstrated a firm understanding of their responsibilities. Staff were able to describe signs that might indicate abuse and knew what to do if they had concerns. One staff member said, “I would report any concerns to a senior or the manager straight away.” Records showed safeguarding incidents had been identified and raised with the local authority in line with the provider’s safeguarding policy. The registered manager had taken appropriate actions to address the concerns and to keep people safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were detailed, holistic and personalised. One person needed support to move with the use of a hoist and sling. Their risk assessment and care plan provided detailed guidance for staff in how to support them, and when and how to use the equipment in the way the person preferred. We observed staff following this guidance, ensuring they explained what was about to happen and providing the person with reassurance and encouragement. The person appeared calm, smiled and thanked the staff for their assistance.

Some people were living with dementia and risk assessments and care plans identified specific details about the impact of the condition and how to support them. For example, a person no longer recognised their own reflection and found this confusing and distressing. Their risk assessment included removing mirrors from their room and the care plan included strategies to support them if they became distressed.

Another person had mental health needs. Their risk assessment included details of their mental health history and signs and symptoms that might indicate a deterioration in their mental health. This included changes in the person’s behaviour and identified factors to be aware of, and the actions staff should take to ensure the person remained safe if they began to feel overwhelmed with anxiety and emotions. Staff knew the person well and were able to tell us about specific actions they would take including removing sharp objects, belts or cords if the person was becoming unwell and contacting the mental health team for older people.

Risks associated with health conditions were identified and assessed. Some people had diabetes, and risk assessments included how to identify if blood sugar levels were too high or too low for the person, what signs or symptoms to look for and what actions to take. Other risks associated with diabetes were identified and assessed including for example, risks to skin integrity and eyesight.

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.

Some environmental risks had not been considered. Some people were able to walk around unaided, including using the stairs. The provider had not assessed risks associated with falls for all stairways. This was discussed with the registered manager on the day of the assessment. They took immediate actions to ensure this risk was mitigated. Following this assessment, the registered manager informed us electronic sensors had been fitted to ensure staff were alerted to people approaching the stairs. They explained this system was working well and this meant people’s risks of falls when using the stairs were reduced.

We observed a tea trolley with a hot tea pot and coffee pot were left unattended for a short time. This meant there was a risk that people could scald themselves. The registered manager took immediate actions to provide alternative cool touch containers to reduce this risk.

Other environmental risks were assessed and managed. For example, some people had been assessed as being at high risk of falls and sensor mats were in place to alert staff when people needed support to move around.

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.

There were enough suitable staff to provide safe care. People told us they did not have to wait long if they needed support and we observed staff were responsive to people’s needs. One person told us, “When you ring the bell they are there very quickly indeed.” Staff described effective systems for deployment of staff. One staff member said, “If we are short of staff because of sickness we use agency workers, and the managers do help out with meal times and with personal care. It’s never a problem.” Staff told us they felt well supported in their roles and had received the training and support they needed. One staff member said, “We get supervision regularly, the managers do listen when we have concerns and you can have a private chat if needed.” Staff had received training that supported them to be effective in their roles. One staff member said, “The training is specific to people’s needs. We all had training in stoma care and catheter care because we admitted people with those needs.”

There were safe systems in place for the recruitment and induction of new staff. One staff member spoke positively about their induction period and said they had shadowed experienced staff members until they felt confident.

The registered manager described how people were indirectly involved in the recruitment of staff. Candidates were asked to sit in a communal area whilst they waited to be formally interviewed. This provided an opportunity for people living with dementia to talk with them in an informal way.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Systems were effective in maintaining a clean environment and managing risks of infection. People told us staff supported them to keep their rooms clean and tidy. Our observations were there were no malodours and each room we saw was spotlessly clean. Staff told us they had completed training in infection prevention and control (IPC) and they had access to the personal protective equipment (PPE) they needed when supporting people with personal care. We observed staff were using appropriate PPE.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People were receiving their medicines safely and as prescribed. Medicines were only administered by staff who had received training and were assessed as competent to administer medicines. We observed a member of staff administering medicines to people. They followed safe practice in line with the National Institute for Clinical Excellence (NICE) guidance and supported people in a personalised way. The provider used an electronic system for medicine administration records (MAR) and these were checked daily to ensure people were receiving their medicines as prescribed. Some people were prescribed as required or PRN medicines and there was clear guidance for when and how to administer these medicines. One person told us, “If I need tablets (for pain) I only have to ask and they will go and get them for me.” Some people were receiving their medicines covertly (without their knowledge and consent). Records showed family members, and the GP, had been involved in the decision to administer medicines covertly, in the person’s best interest.