Avon Reach

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 78 (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.

The provider had established effective systems to identify, review and learn from incidents, accidents and concerns. Records demonstrated safety events were appropriately reported, investigated and reviewed through monthly clinical governance processes. Leaders analysed themes and trends relating to incidents including falls, medicines, infections and wound care and used this information to identify risks and implement preventative measures where required.

Learning from incidents was shared across the service through handovers, department meetings and other team forums. Staff told us they felt confident reporting incidents and concerns and that leaders responded appropriately when issues were raised. Leaders demonstrated how reflection and learning resulted in changes to practice. For example, they identified that some newer staff lacked confidence in providing oral care for people receiving end of life care and introduced additional observations, supervision and support, with learning shared across staff teams to improve consistency. Falls were also reviewed to identify contributory factors and implement additional measures. A relative described how a pressure mat had been introduced following repeated falls, enabling staff to provide more timely support. This demonstrated an open culture in which learning from incidents was used to inform practice and strengthen people's safety.

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.

The provider had effective systems in place to support safe admissions, transitions and continuity of care. Records demonstrated a structured approach to assessments before admission, on admission and during the initial weeks following admission. Assessments considered people's physical, emotional, communication and healthcare needs and provided staff with clear information to support safe and personalised care. This meant people received care that reflected their needs and preferences during periods of transition.

The provider worked with people, relatives and professionals to ensure transitions were planned and managed safely. People told us they were provided with information about the service and records demonstrated people and their families were involved in discussions about admissions and ongoing care. Staff described how a prospective resident had been invited to visit the home and experience the environment before deciding whether to move in. During the inspection, we also observed staff completing detailed preparations for a person's respite admission, including environmental checks, equipment checks and ensuring the room was welcoming and ready for arrival. A person told us, “I was very anxious, but the staff made me feel at home very quickly.” This demonstrated a coordinated and person-centred approach that supported people to move into the service safely and in a planned way.

Staff worked effectively with healthcare professionals to ensure continuity of care when people's needs changed. Records showed referrals were made appropriately and in a timely manner when specialist support was required. Staff described how information received from hospitals and other professionals was shared through handovers and team meetings to ensure care plans reflected people's current needs. One staff member explained how additional safety measures and care plan updates had been implemented following a person's return from hospital with increased support needs, adding, "Handovers are very good in helping us share with staff new information, changes and outcomes."

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.

The provider had effective systems and processes in place to protect people from abuse, neglect, discrimination and avoidable harm. Safeguarding was embedded within training, supervision and team meetings, and staff consistently demonstrated a good understanding of how to recognise and report concerns. Policies reflected current guidance and systems were in place to ensure people who may be deprived of their liberty were appropriately protected.

The provider worked effectively with partner agencies to ensure safeguarding concerns were identified, reported and managed appropriately. Records demonstrated safeguarding concerns were shared promptly with relevant authorities where incidents met safeguarding thresholds. The service maintained a safeguarding log which provided oversight of concerns, referrals, actions taken, lessons learned and outcomes, enabling leaders to monitor safeguarding activity and ensure concerns were progressed appropriately.

There was a strong culture of safety, dignity and respect within the service. Safeguarding information was displayed throughout the home and accessible to people, relatives and visitors, helping to raise awareness of how concerns could be reported. During the inspection, we observed warm, supportive and person-centred interactions between staff and people. The atmosphere was calm and people appeared relaxed and comfortable in the presence of staff. Feedback from people and relatives reflected confidence in the care provided. One person told us, "This place is very safe and like a big family." Relatives told us, "[Person's] being well looked after" and "I think [Person] gets very good care. People seem to be happy." This demonstrated people felt safe, supported and protected from harm.

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.

The provider took a person-centred approach to identifying and managing risks. Records demonstrated risk assessments were completed, regularly reviewed and reflected people's individual circumstances, preferences and behaviours. Risks were translated into practical guidance within care plans, supporting staff to balance people's safety with their independence and personal preferences.

Staff managed risks in a positive and proportionate way, supporting people to maintain independence and choice wherever possible. For example, detailed risk assessments demonstrated how staff reduced the risk of falls for 1 person through tailored measures including sensor equipment, environmental adaptations and additional support strategies, which had contributed to a reduction in falls compared to when the person lived at home. Another person was supported to use their wheelchair independently as a form of daily exercise after risks had been assessed and mitigated. During the inspection, the person proudly told us, "I am doing my daily exercises." This demonstrated staff enabled people to continue doing things that mattered to them while managing risks safely.

During the inspection, we observed staff supporting people safely and in line with their assessed needs. Staff demonstrated a good understanding of risk management and how to respond to individual health risks, including choking, seizures and breathing difficulties. Relatives also described how safety measures had been introduced to reduce risks while maintaining people's independence and freedom of movement. This demonstrated people were supported to manage risks in a way that promoted safety, wellbeing and autonomy.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had effective systems and processes in place to identify, monitor and manage environmental risks. Records demonstrated essential servicing and safety checks were completed within recommended timescales and environmental risks were monitored through regular health and safety audits. Regular health and safety audits provided oversight of environmental risks, with actions identified, monitored and completed where improvements were required. This demonstrated the provider took a proactive approach to maintaining a safe environment for people.

The provider managed environmental and fire safety risks effectively. Fire safety arrangements were effectively managed. During the inspection fire exits and escape routes were clear, fire doors were unobstructed and no immediate concerns were identified. The environment was clean, well maintained and free from avoidable hazards. Corridors and communal areas were clear, hazardous substances were stored securely, and oxygen was stored safely.

Adaptations such as handrails, grab rails and raised toilet frames supported accessibility and reduced risks associated with falls. People, relatives and staff consistently described the environment as safe and well maintained. One person told us, "Yes, the home is well maintained, and I think it is safe all around," while a relative said, "The corridors are kept clear, there are handrails and slopes but nothing to trip over." This meant people lived in an environment that promoted their safety and independence.

Staff demonstrated awareness of environmental risks and took appropriate action to minimise them. During the inspection, a member of staff explained they would move a person's Zimmer frame after use to prevent it becoming a trip hazard, having first consulted the person and gained their consent. We identified two bed rails that remained attached to beds despite not being in use and without protective bumpers in place. Although no immediate risk had been identified, the registered manager took prompt action and instructed staff to remove them during the inspection.

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.

The provider had effective systems in place to recruit suitably qualified, skilled and experienced staff. Recruitment records demonstrated appropriate pre-employment checks were completed, including verification of identity, employment history and criminal record checks. Similar processes were in place for agency staff and volunteers, helping reduce the risk of unsuitable individuals providing care and support to people.

The provider supported staff to develop the knowledge and skills required for their roles through a comprehensive induction, training and competency framework. New staff completed a structured induction programme, including a period of supernumerary practice, before working independently. Staff also had access to ongoing learning and development opportunities, with competency assessments completed regularly to ensure safe and effective practice. A staff member told us, "The induction was very good, it really did help a lot." Training records demonstrated staff completed mandatory training and accessed additional learning relevant to people's needs.

There were sufficient staff available to meet people's needs safely and effectively. During the inspection, staff were visible throughout the home, responded promptly to call bells and supported people in a calm, patient and unhurried manner. Leaders maintained a visible presence and oversight of the service. Feedback from people, relatives and staff was consistently positive. One person told us, "There's enough of them around." A relative commented, "The staff are well trained, I've no concerns from that point of view." This demonstrated people received support from sufficient numbers of knowledgeable and competent staff who understood their individual needs.

The provider thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading.

The provider demonstrated a comprehensive and proactive approach to infection prevention and control (IPC), supported by strong leadership, effective governance and a culture where IPC was understood as a shared responsibility. Infection trends, incidents and audit findings were routinely reviewed through governance processes, enabling leaders to identify themes, implement preventative measures and maintain oversight of IPC risks. Staff completed regular training and competency assessments and demonstrated a good understanding of their responsibilities in preventing and controlling infection.

The provider demonstrated a strong commitment to preventing infections through partnership working and innovative cleaning practices. Records demonstrated that people were provided with comprehensive information and supported to make informed choices regarding seasonal vaccinations. Staff were also supported to have seasonal vaccinations if they wished to have them. The service had invested in a stabilised aqueous ozone cleaning system, which converted tap water into a cleaning and sanitising solution that was independently tested to British Standards and achieved high-level reductions against a range of bacteria and fungi. Leaders told us the decision was driven not only by infection prevention but by a desire to reduce people's exposure to cleaning chemicals. This was particularly beneficial for people living with asthma, chronic obstructive pulmonary disease (COPD) and other respiratory conditions, as the system produced no chemical vapours or residues. This meant people benefited from both highly effective infection control and a healthier living environment, demonstrating how the provider had identified and addressed risks associated with traditional cleaning methods rather than relying solely on established approaches.

Highly effective environmental controls further reduced the risk of infection transmission. During the inspection, the home was visibly clean, tidy and free from malodours. Handwashing facilities and hygiene signage were readily available throughout the building. Laundry, waste management and cleaning processes operated in line with best practice guidance, with appropriate segregation of clean and dirty laundry, secure waste storage and effective infection control measures observed throughout the home. Equipment, mattresses, pressure cushions and bed linen were clean and well maintained, and kitchen practices minimised the risk of cross-contamination. This meant people lived in a clean, safe and healthy environment.

The effectiveness of the provider's approach was reflected in positive outcomes and consistently positive feedback. The provider routinely reviewed infection trends and outcomes alongside environmental audit results to evaluate the effectiveness of its IPC arrangements. The service's annual IPC statement confirmed there had been no gastrointestinal or respiratory outbreaks during the previous 12 months and audit systems demonstrated consistently high standards of environmental cleanliness. Whilst leaders could not attribute these outcomes to this intervention, evidence reviewed demonstrated the provider had implemented multiple proactive measures to reduce infection risks and continually evaluate their effectiveness.

The provider's innovative approach delivered benefits beyond infection prevention. People were not exposed to chemical cleaning residues on surfaces they touched daily, and those living with respiratory conditions benefited from an environment free from cleaning-related airborne irritants. The removal of traditional wet mopping processes also reduced potential slip hazards in communal areas, supporting people's safety and independence. In addition, leaders told us healthier working conditions had reduced irritation symptoms amongst some housekeeping staff, supporting staff wellbeing and continuity of care for people living in the home.

People and relatives consistently praised the cleanliness of the service, with 1 person telling us, "The rooms are kept very clean and tidy. The whole place is spotless really," and a relative describing the home as, "It's like a very nice, clean, comfortable hotel. It always smells fresh, flowers in reception." This demonstrated how the provider had adopted an innovative and evidence-based approach to infection prevention that both protected people from infection and improved their everyday living environment.

The provider continually evaluated the effectiveness of innovative practices and used audit findings, infection data, staff feedback and observations of people's experiences to determine whether changes were achieving the desired outcomes. What distinguished the provider's approach was its willingness to move beyond traditional cleaning methods and adopt evidence-based innovation that considered people's wider health and wellbeing. Rather than focusing solely on infection prevention, leaders evaluated the potential impact of cleaning processes on respiratory health, environmental exposure and people's everyday experiences. This demonstrated a culture of continual improvement where innovative practice was used to enhance both safety and quality of life.

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.

The provider had systems and processes in place to support the safe management of medicines and treatments. During the inspection, we observed medicines being administered safely and respectfully. Medicines were stored securely, stock levels corresponded with records and medicines checked during the inspection were within their expiry dates. This demonstrated people generally received their medicines safely and as prescribed.

The provider adopted a person-centred approach to medicines management that reflected people's individual needs and preferences. Personalised protocols were in place for medicines prescribed on an as-required basis and provided clear guidance to support safe and consistent decision-making. Staff demonstrated a detailed understanding of people's health conditions and medicine requirements and explained how support was tailored to individual needs. Records also showed people with complex healthcare needs, including those requiring insulin, received appropriate monitoring and oversight, with clear guidance available to support staff in responding to changes in people's health. This meant people received medicines and treatment in a way that promoted safety, consistency and positive outcomes. Medicines records were generally well maintained and governance systems provided oversight of medicines management. Medication Administration Records (MAR) contained no unexplained gaps, topical medicines were applied as prescribed and medicines audits had not identified significant concerns. Competency assessments demonstrated staff had the knowledge and skills required to undertake medicines-related duties safely.

We identified some areas where oversight could be strengthened, including the recording of medicines refrigerator temperatures, monitoring arrangements for a medicines trolley, and records relating to transdermal controlled drug patches. We also identified isolated delays in the administration of some time-specific medicines which were not subject to formal audit. The provider responded promptly by reviewing practices, updating policies and reinforcing expectations with staff. There was no evidence people had experienced harm and subsequent reviews indicated the issues identified were isolated rather than systemic. One person told us, "Staff help me with medication and I think they handle my medication safely." This demonstrated medicines were generally managed safely, and leaders responded appropriately when opportunities to strengthen governance were identified.