Avon House Rest Home - Balcombe

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 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 promoted a positive learning culture where incidents, feedback and day-to-day experiences were used to improve the quality and safety of care. Learning from incidents was discussed through regular staff meetings and reflected on with the wider staff team to promote consistent practice and reduce the risk of similar events occurring again. For example, following a person becoming unwell, staff reflected on the incident and reinforced the importance of recognising early signs of deterioration following escalation procedures and seeking timely support from healthcare professionals. This learning was shared with the wider staff team and incorporated into everyday practice.

Leaders encouraged staff to speak openly about practice, reflect on their experiences and identify opportunities for improvement. A staff member told us, “The managers are always guiding me, and teaching me. They talk to me politely”. This approach promoted an open learning culture where staff felt able to reflect on practice, learn from experience and continuously improve the care people received.

The provider had safe systems, pathways and transitions in place to identify, monitor and respond to risks, helping to reduce the likelihood of harm and promote people's safety.

Staff were able to recognise changes promptly, follow internal guidance and work closely with healthcare professionals to ensure appropriate action was taken.

For example, when a person became unwell, staff recognised the early signs of deterioration and promptly followed the provider's escalation procedures. They contacted the emergency services, informed the persons next of kin and the registered manager and commenced additional monitoring including checking oxygen saturation where clinically indicated in line with healthcare professionals’ advice. This supported early recognition of deterioration and enabled concerns to be escalated promptly resulting in the person being conveyed to hospital for further assessment and treatment. The person was assessed in hospital and later returned to the service where staff continued to provide appropriate care and support while monitoring their recovery. Over time, the person returned to their usual level of functioning, supported by ongoing care.

The systems enabled care to be reviewed and adapted in response to the person's changing needs, supporting coordinated care and consequently, positive outcomes

The provider worked with people, their families and partner agencies to keep people safe and protected from harm. People and relatives told us they felt safe and confident with the care provided. A relative told us, “Yes 100%, otherwise I wouldn`t put mum there. Avon House is a haven for mum`s peace and security”.

Staff had completed safeguarding training and demonstrated understanding of safeguarding principles. A staff member told us, “Safeguarding is about being aware of our residents` wellbeing and protecting them from harm and abuse.”

Some people had deprivation of liberty safeguards(DoLS).DoLS is a legal protection order used when a person`s freedom needs to be restricted to keep them safe, for example in a care home setting. Staff understood what this meant to people, ensuring any restrictions were lawful, proportionate and applied in their best interests to protect people's rights and well-being.

Safeguarding and whistleblowing were regular agenda items at staff meetings, reinforcing staff responsibilities to speak up. Clear reporting pathways and safeguarding information were readily available, and systems supported the monitoring and management of safeguarding concerns. These arrangements promoted a culture where safeguarding concerns were recognised, prioritised and acted upon promptly, supporting people's safety and well-being.

The provider worked with people to understand and manage risks in a way that supported their safety, well-being and independence. Care plans and risk assessments provided staff with guidance on how to manage known risks while enabling people to continue doing what mattered to them.

The provider also responded proactively to emerging risks. For example, during the recent heat wave, staff recognised that people`s age and underlying health conditions placed them at greater risk of the effects of extreme heat. Therefore, a heatwave action plan, informed by UK Health Security Agency guidance(UKHSA),was implemented to help reduce the potential risks associated with extreme heat. This included monitoring room temperatures, supporting people to remain cool and well hydrated, adapting daily routines and where possible avoiding the hottest parts of the day and sharing clear guidance with staff and people to promote a consistent approach to keeping people safe. These measures helped people understand and manage potential risks while supporting their safety, well-being and comfort.

The provider did not always identify and manage environmental risks effectively. During the assessment, we found some risks had not been fully assessed or mitigated, including unrestricted access to hazardous substances, accessible window restrictor keys, and the absence of a risk assessment for balcony access.

The provider responded promptly, during the assessment, by securing hazardous substances, removing window restrictor keys from accessible areas, and completing a risk assessment for the safe use of the balcony.

Despite these shortfalls, the service was well maintained and accessible. Staff had received health and safety training and understood how to report environmental hazards and used equipment safely. Personal emergency evacuation plans, a business continuity plan, and onsite maintenance arrangements were in place to support people's safety and the continuity of care during emergencies.

A person described the service as, “a warm and accommodating environment”.

The provider made sure there were enough qualified, skilled and experienced staff, to meet people`s needs safely. Staff told us there were sufficient staffing levels to meet people's needs, which was reflected in the rotas. Consistent staffing arrangements and low use of agency staff promoted continuity of care, enabling people to receive support from staff who knew them well.

We observed there were enough staff to support people and staff took time to engage with people in a meaningful way, offering reassurance and conversation alongside care. This helped people feel valued, reassured and at ease. A person told us, “Staff are very helpful, they have a very responsible job looking after people. They do it well, they work their socks off.”

Through their recruitment processes, the provider ensured suitable staff were employed to provide safe and effective care. Staff received training relevant to their roles and were supported through regular supervision and appraisals, helping them develop the knowledge and skills needed to meet people`s needs safely. A relative told us, “Yes, they certainly have the skills to look after her, I do think so.”

The provider assessed and managed the risks associated with infection prevention and control (IPC).Staff had completed IPC training and understood the importance of maintaining a clean and safe environment. A staff member told us, "It's important that our residents live in a clean home. It's a way of protecting them and us from infections.”

We observed staff following safe IPC practices, including working bare below the elbows (with forearms free from clothing and jewellery);maintaining appropriate hand hygiene and using personal protective equipment(PPE) correctly. Staff changed PPE appropriately between different care tasks, such as providing personal care and supporting people with meals. PPE stations were readily accessible throughout the service and posters displayed around the home reinforced good hand hygiene and IPC practices.

We observed the premises were clean and equipment was cleaned between uses. These measures helped reduce the risk of infection and supported the safety and well-being of people, visitors and staff. A relative told us, “It’s always clean, it doesn't smell.”

The provider had systems in place to support the safe storage, administration and disposal of medicines. Medicines were managed through clear governance processes with appropriate escalation to healthcare professionals where concerns or errors were identified.

We observed appropriate risk assessments and monitoring in place for medicines requiring additional oversight, helping to reduce the risk of errors and promote safe administration.

There was evidence of partnership working with external professionals to support safe practice, to ensure treatment remained safe, appropriate, and reflected people's changing health needs.

Staff completed medicines training and competency assessments and demonstrated a good understanding of safe medicine management.

People were supported to take their medicines in a person-centred way that respected their preferences, choices and independence. The provider had arranged for individual medicine profiles for people, as guidance for staff on how each person preferred to receive their medicines.

This helped ensure people's medicines were administered safely while acknowledging and respecting their capabilities, preferences, and choices.