Archived: Avon House

On the day of our visit we found that a nurse who was new to the service was responsible for the care delivered to 8 people. The nurse, despite leading the unit, was unaware of the needs of people or the arrangements in place to meet their need.

The care and treatment provided to people was not recorded so we could not judge whether their needs were being met safely.

We observed some very positive interaction and support for some staff but we also observed some inappropriate interaction and comments.

Whilst staff had received training to improve their safeguarding processes we found evidence that the service had failed to respond adequately and appropriately to known safeguarding concerns which may have put the people at further risk. We also saw evidence of a person being unlawfully restrained.

People's medication was poorly managed and we found that their health was put at risk because they did not always have their medication as prescribed.

New nursing and care staff had been recruited and we saw there were effective processes in place for inducting them into their new role. However at the time of our visit we saw that care was led by agency nurses who were not adequately inducted and lacked knowledge about people's needs and presenting risks.

The service was not adhering to the provider's incident reporting protocols which presented risks to people's safety and welfare.

The service failed to adequately secure people's records and when required were unable to locate these promptly.

People we spoke with told us they were 'very happy' and one person said 'there are good days and not so good days, it's so, so'.

We found people's needs were assessed and care and treatment was planned however it was not always delivered in line with their individual care plan. We also found care was not always delivered in a way that ensured people's safety and welfare. People were at risk of developing pressure related injuries as they did not receive care in accordance with their care plan. We saw staff did not review and update care plans to reflect people's changing needs.

People told us they felt safe, however we found people were not protected from the risk of abuse because staff did not follow the safeguarding policies and procedures in full.

People told us staff were 'fantastic' and 'very kind'. One person told us the staff were 'all very nice'. Staff told us they had access to supervision, appraisal and training however the providers training records showed staff had not completed training as required.

Risk management systems were in place but there was no evidence that action was taken to address identified issues.