Avalon Clarence Gardens

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.

This is the first assessment for this registered service. This key question has been rated 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.

The provider had policies and procedures for responding to incidents, accidents and complaints and staff we spoke with were knowledgeable about these. Staff told us they were confident about how to respond and report correctly.

The provider conducted investigations when incidents occurred and took appropriate action to prevent recurrences. We saw that ‘lessons learned’ were discussed and shared with staff. Staff attended regular meetings, which helped ensure any learning from events was shared and actioned.

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 service had developed a structured admission pathway to promote continuity of care and positive outcomes

Referrals and assessment information were received from the local authority, enabling the provider to determine whether people's needs could be met safely. People being assessed for the service and their families, were encouraged to visit to meet staff and become familiar with the service.

A pre-admission call was made to families before any subsequent stay at Avalon Clarence Gardens to identify if there were any changes to people’s support needs, medicines and the person’s wellbeing. This helped to ensure a seamless transition between the person’s home and the service. Care plans and risk assessments updated where needed.

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 and their relatives told us they were happy and felt safe at the service. During the assessment we observed staff providing care in a safe and respectful manner. Safeguarding procedures were in place, and staff had a clear understanding of how to report concerns. Staff told us they felt confident the management team would respond to concerns promptly.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Managers and staff understood MCA and had received relevant training. A DoLS tracker provided oversight and monitored the progress of applications and the manager had systems to ensure applications were made for DoLS to be renewed before they expired.

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.

People had detailed care plans and risk assessments in place to guide staff in supporting their safety, independence and choices. The provider ensured support was safe and fully met people’s needs, while also enabling people to do the things that mattered to them, for example, 1 person enjoyed craft work which involved using a hot glue gun. An incident occurred when the glue gun was knocked from the table and hot glue landed on another person. The provider recorded the incident, updated the risk assessment and discussed the risks with the person. Additional measures were agreed to reduce the risk of recurrence while enabling the person to continue enjoying their hobby safely.
Staff worked closely with people to help them understand and manage risks. Risk assessments guided staff on how to support people safely and were reviewed frequently.

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

Effective systems were in place to ensure the premises and equipment were safe, including regular maintenance checks to meet health and safety regulations and fire safety arrangements. Personal Emergency Evacuation Plans (PEEPs) were in place, accessible, reflected people’s individual needs and provided clear guidance for staff.

The environment was clean and comfortable, but some areas needed redecorating, this was scheduled as part of a refurbishment plan.

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 safe recruitment practices in place which ensured suitable people were employed. Staff told us they received an induction on commencement of employment including mandatory training to ensure they had the knowledge and skills to undertake their duties.

We found there were sufficient staff to meet people’s needs. Vacancies were covered by agency staff to maintain safe staffing levels, but staff told us that this created additional pressures at times as agency staff could not administer medicines.

A relative told us, "It's good (staffing) [person] seems to have the same four people on shift when they are there." Following our assessment the provider was taking action to recruit staff and reduce reliance on agency staff.

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.

The service was visibly clean and hygienic, and staff were observed wearing appropriate personal protective equipment (PPE). Records showed cleaning schedules were completed and monitored. Monthly IPC audits were carried out. Staff completed infection prevention and control (IPC) training.

The service involved people and their families in the planning of their care. However, some improvements were needed in medicines related documentation and governance arrangements.

Prior to admission the service worked closely with family and carers to ensure that they had the most up to date medicines information. Medicines administration records (MARs) were then generated by the service; they contained all necessary information including cautionary labels.

Detailed protocols including those for 'as required' medicines were in place to support staff in safely administering medicines. Information for the safe use of enteral feeding tubes such as PEGs was available. However, the flush information recorded required updating due to a recent change. The service clarified the flush requirements and amended this after the assessment.

For 2 of the 4 people reviewed, allergy information was not recorded on the MAR. The service took action to amend this during the assessment.

Where people were prescribed topical preparations, body maps and records of administration were made. Transdermal patch records clearly showed the location of application.

The provider had a medicines policy and audits were in place. Staff had completed medicines training including training for specialist delegated healthcare activities. The service had developed a risk assessment and action plan as competency assessments for delegated task were not in place.