Avenues South Hampshire Services

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 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 legal regulation in relation to safe care and treatment, safeguarding and staffing.

This service scored 41 (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. They did not always listen to concerns about safety and did not always investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

We found concerns were not always thoroughly investigated to ensure learning outcomes were clear and people were always supported to remain safe. For example, we found an incident which noted 1 person’s medicine was administered covertly, and without any witnesses despite their care plan stating the medicine should be given non-covert with a spoon. Covert administration of medication is the practice of administering medicines to a person in a disguised format without their knowledge or consent. We found this incident was not reported to CQC, and the incident form was incomplete. For example, the changes which had been made following this incident was marked as ‘zero’. There was no evidence to demonstrate this incident had been investigated to identify how long this covert administration had been going on for. Also, the provider noted the person was ‘not affected.’ However, there was no evidence recorded to show assurance was sought from healthcare professionals that it was safe to have their medicine administered in certain food, and to check the effectiveness of the medicine administered in this way.
We reviewed staff meeting minutes and found a lack of evidence to demonstrate incidents were always discussed with all staff to drive improvement and implement an effective learning culture. We noted there was no significant feedback or discussion from staff during these meetings. Furthermore, it was unclear how the provider ensured all staff, who were unable to attend the meetings, were involved in any learning outcomes.

The provider told us they held monthly safeguarding meetings and senior leaders completed audits each quarter, which we reviewed as part of this assessment.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.
We found people were not always supported through effective working with healthcare partners. For example, a person living with diabetes did not have evidence of input from healthcare professionals regarding their diabetic foot check. A diabetic foot check involves a visual and physical examination of the feet to identify problems, assess risk, and ensure proper care.After the assessment, the provider told us they strengthened people’s care records by updating diabetic care plans and included references for foot checks.
Some relatives told us they did not think the service and other professionals worked well together to support their family member. Some relatives told us they did not think information was always shared between teams and services, to ensure continuity of care and when people were referred between services.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.
Although the provider maintained an incident log, we found some incidents where people were not safeguarded to ensure their safety and wellbeing was supported and protected. For example, we found 1 incident involving a person was recorded inappropriately by a member of the public. There was no evidence a safeguarding referral was raised around this incident. Although the provider recorded follow up actions to be taken after this incident, there was no evidence to demonstrate people were protected from this risk of harm and abuse.
Another person was noted to have a piece of rubber in their mouth, and staff attempted to use a spoon to retract this out of their mouth. We found no evidence this incident was safeguarded.
These examples of incidents showed a breakdown in the oversight of safeguarding and failure to recognise the severity of some incidents.
We received mixed feedback from staff and relatives. Staff told us, “Safeguarding is a very big topic in care work, we’ve all had the training.” However, some relatives told us, “I am not sure if staff would speak up for [family member] in a situation, I can’t answer that, my opinion is staff all watch out for each other. They back each other up.”
 

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Some people’s medicines had associated risks, which are recognised as part of Medicines Healthcare products Regulatory Agency (MHRA) alerts. The provider was unable to evidence and demonstrate an understanding of associated risks with specific medicines which they administered to people using the service.
Some people’s care records failed to clearly identify how they would be safely and appropriately supported to ensure they were safe and protected from abuse. For example, 1 person’s support plan mentioned staff can help by giving them space, giving them a hug and stroking their hair. However, this person also had a risk assessment in place for sexual safety which stated these examples of physical contact such as hugging and stroking their hair has been risk assessed as inappropriate behaviour by staff, and staff were supposed to redirect this person due to sexual safety risk. Staff we spoke with confirmed this person liked to have their hair stroked and this was done. However this information was contradictory, and it was therefore unclear how the provider ensured this person’s sexual safety was maintained. Another person was known to attempt to touch staff inappropriately, however they did not have a sexual safety risk assessment in place at the time of our visit. This meant this known risk was not acknowledged and documented to ensure people were always protected and risks were mitigated.
 

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.
We reviewed staff meeting minutes and found staff left keys in the medicine’s cabinet. This did not demonstrate staff always controlled potential environmental risks to people.
We noted personal emergency evacuation plans were in place for people using the service. However, the provider did not demonstrate there were environmental risk assessments in place for people at the time of our visit. This meant all risks were not identified and controlled, to ensure people were protected from the risk of harm.
One person had emergency oxygen in place for seizure episodes. The masks used for this therapy did not have any labels, or clear packaging which detailed if the mask was for adults or paediatrics, and when the expiry date was to ensure they were still effective and fit for use.After the assessment, the provider told us they were provided with new masks, and these are clearly labelled with expiry dates.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.
Some relatives told us they did not think all staff had the training and skills to provide specific and individualised care to people.
The provider did not ensure training was kept up to date for staff who were providing care for people. We found at least 5 staff were administering insulin whilst their training and competency assessments were out-of-date. Furthermore, safeguarding and moving and handling training were not in date, or regularly refreshed, for several staff actively supporting people in the service.
We requested evidence of assessor competencies for the assessors completing staff competency assessments. The provider failed to evidence staff completing these were skilled and qualified to do so.
Furthermore, some medicines cannot be routinely administered by a care worker. For example, injections (such as insulin) or medicines administered via a feeding tube are clinical or nursing tasks. A registered nurse (RN) can delegate the administration of these medicines to a care worker. However, we found the provider did not demonstrate who maintained responsibility for these tasks as they were delegated by the managers and not by a nurse.
We found some staff were supporting people with rescue medicine. Rescue medication is the term used to describe medicine given in an emergency to relieve symptoms quickly. However, we found some staff had not completed the necessary training for administering this medicine. This meant people were not always supported by suitable and skilled staff.
Although the provider’s policy stated the Care Certificate would be completed within 3 months of employment for staff new to care, we found new staff were not always enrolled on this course and had not completed this certificate. The Care Certificate is based on 16 standards, that health and care professionals adhere to in their daily working life which individuals need to complete in full before they can be awarded their certificate.
 

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.
Relatives told us they did not have concerns regarding the cleanliness of the environment, and staff wore personal protective equipment. One relative told us, “The accommodation is good and is clean and tidy, it is in a lovely environment.” We saw the provider completed audits which included areas such as infection, prevention and control.
 

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.
We found some products used as part of people’s medicinal care had expired at least 4 months before the inspection, this included adhesive patches and liquid solution for checking glucose and ketones. The provider did not ensure they maintained effective oversight and safe medicines management to ensure people’s medical care products were monitored and in date.
Staff told us 1 person’s medicine was crushed when administered. CQC informed the provider of this information, and the provider confirmed they were not aware of this, and we found no information regarding crushing medicines was recorded in any person’s care plan. Therefore, staff were not administering medicines in line with the prescriber’s guidance. We also could not be assured that the medicines staff were administering were having the desired therapeutic effectiveness. There was also no evidence this form of administration was authorised by a healthcare professional before the medicine was crushed.
1 person had their medicine transferred from liquid solution into capsules to support administration. Furthermore, there were no training and competency records to confirm staff were skilled to complete this task.
We found there was a lack of consistency in recording the administration and outcome of ‘as required’ (PRN) medicines. A failure to maintain accurate records of medicines increases the risk of medicines related harm.
Some PRN protocols were not in place at the time of our visit. The provider confirmed some protocols were still with the GP to sign, and they had been with the GP for at least 2 months. However, this did not assure us the provider was safely administering PRN medicines with clear guidance for staff to follow. Also, some PRN protocols stated variable doses, such as “2 to 4 spoonful’s” however, staff did not have clinical knowledge to make these decisions around administering variable doses. This meant staff were administering PRN medicines without clear and authorised guidance from a healthcare professional.
Some people’s medicines administration records (MARs) showed several gaps, unfinished entries, inconsistencies with administration recording, and incorrect signing from staff.
Not all staff currently administering medicines had renewed their training and competency assessments in line with best practice guidance. This meant there was a risk medicines could be administered by staff who did not have the skills to do so safely. The systems used to audit the medicines were ineffective, as they had not identified all issues we found during this assessment. We shared our findings with the provider throughout our inspection.