Avon View

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 inspection we rated this key question good. At this inspection the rating has to remained good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People and relatives told us they knew how to raise concerns. A relative said, “Regularly we have an afternoon tea with the staff where we can raise any suggestions or concerns.”

The service had a robust system in place for reporting, reviewing and analysing incidents and accidents. The registered manager reviewed accidents and incidents across the service regularly, to identify trends and themes. People’s care plans and risk assessments were updated following incidents if required. The registered manager told us lessons learned were shared with staff through staff meetings to prevent a recurrence.

Records confirmed staff were given the opportunity to review their practice in an incident or accident they were involved with during their supervisions.

The service 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 an established process to ensure people’s information was provided and sent with the person if they were admitted into hospital.

Health and social care professionals were complimentary about working with the service and maintaining safe systems of care, especially when people moved between different services. A professional said, “The service is very good at linking with different agencies like dieticians, Speech and Language, Tissue viability and the practice.”

Staff told us they had access to information about people, so they knew how to support them safely. One staff member said, “We read the care plan when a new resident arrives. We are the frontline, and we see everything, so we always report to the line manager if there is an update on any residents. For example, if we have any residents that have difficulties swallowing, we will contact the Speech and Language Therapy (SALT) team.” Another staff member told us, “Any updates (regarding changes in people’s care needs) are usually told during handovers for us to ensure we are aware of any changes.”

Relatives told us the service communicated well with them and updated them regularly when required.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

People told us they felt safe living at the service. A person said, “All the time I’m safe.” A relative told us they witnessed staff interacting with people at the service, “Following safe codes of practices when staff deal with the people.”

Staff told us they knew how to raise safety concerns within the service. A staff member said, “When there are concerns, I always report my concerns to my line manager. If the concern is about the line manager, I will go to higher management. I also can contact the council safeguarding team and CQC to talk about my concerns.”

Staff received training in safeguarding, and the provider had up-to-date safeguarding and whistleblowing policies in place.

The provider had a robust process to ensure concerns were reported to the local authority without delay. The registered manager had an overview of all concerns raised. This allowed them to identify patterns and monitor outcomes, supporting continuous improvement in safeguarding practices.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care services, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. All legal applications had been made in accordance with DoLS.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some relatives told us some staff did not always understand or know how to support their loved ones. This included supporting people with their moving and handling needs and their nutrition and hydration needs.

Some staff told us they did not always know how to support people who displayed distress or anxiety due to their medical conditions. Some staff told us they felt they were not supported to help people who displayed distress and the training provided was insufficient. In other areas, for example medicines and infection prevention and control, staff had received training and told us it was effective.

Following our feedback the provider confirmed they contacted the training organisation for advice and support to communicate to teams’ expectations and requirements.

The service 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.

Staff told us they knew how to report concerns relating to the environment. We received mixed feedback from staff relating to how quickly these concerns were addressed. Some staff members told us the service did not respond quickly, and some said the service addressed environmental concerns without delay.

The service used external contractors to undertake some of the environmental checks such as gas, electrical and water hygiene. The service had an action plan for all the work identified during recent fire checks.

The provider had systems in place to promote safe environments; however these were not always effective in identifying the shortfalls found during this inspection.

Some fire doors which should have been locked, were left unlocked and therefore accessible to people. We observed 1 remote for an armchair with exposed electrical wires. The registered manager responded to our feedback by removing the armchair.

On the first day of the inspection, we observed unlocked cupboards in the kitchenettes containing cleaning products. People had access to the kitchenettes which meant there was a risk these products could contribute to adverse incidents or accidents. We informed the provider of the cleaning products and were told they would be removed. On the second day of the inspection some cleaning products remained in the unlocked cabinets. They were then removed. Two months prior to our inspection, the provider’s internal audit had identified the kitchenette cabinets were unlocked, and cleaning products were unsafely stored. However, they had failed to rectify this shortfall without delay.

The door to the lift machinery was unlocked during the first day of the inspection. The registered manager ensured the onsite maintenance staff locked the door when they were not inside the room.

We observed people’s rooms were clean, and personalised.

The service did not always make sure they worked together well to provide safe care that met people’s individual needs.

Health and social care professionals told us they did not always feel there were sufficient staff available to meet people’s needs. Comments included, “The service has an understanding of people’s needs but I have found for many years now that some people’s needs sometimes cannot be met as there is not the staffing to support people to go into the garden when they want and spend quality time out there” and “I have seen positive improvements with the service, but staffing continues to be an issue as I can never find anyone that is willing to talk to me or has the time. And people consistently express to me that they cannot find staff and don’t feel there is anyone who will take them into the garden or spend time with them to do things they want,” and “I am aware of the widespread use of Agency staff, for many of whom English is not their first language and communication can be tricky.”

Staff told us they felt there were not enough of them working at the service. Comments included, “Most of the time we are short staffed… Most residents need more attention,” and “We are always busy (…) and worried about supporting people’s needs. (…) Some people need assisting with feeding and fluid. We can't be everywhere.”

The service had a system to determine the number of staff required in relation to people’s needs. The system indicated that staffing levels were sufficient. The provider told us they were looking at other systems to determine the number of staff needed. Following our feedback, the provider told us the expectation was all staff members helped during mealtimes. The provider confirmed they were working with the team to review how tasks were allocated to specific roles with the aim of increasing staff availability during busier periods, such as mealtimes.

Most people and relatives were happy with the way they were supported. A person said, “(Sometimes I have to wait for staff) longer, but they do apologise and explain why they kept me waiting.” A relative told us, “The management often will go beyond their duty and provide 1 to 1 support when needed and communicate well.”

Recruitment procedures were in place to ensure the required checks were carried out on staff before they commenced their employment. This included enhanced Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the premises to be clean.

People confirmed staff used Personal Protective Equipment (PPE) when supporting them. A person said, “My bedroom gets cleaned regularly.” Comments from relatives included, “I noticed [person’s] bathroom is not as clean as it should be plus [person’s] cleanliness at times is not well maintained,” and “There could be more attention given to individual rooms, cleaning of side tables and removing dirty glasses and cups from rooms.”

We observed the service to be clean on both days of our inspection. Staff told us they had access to PPE.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People received their medicines safely in the way prescribed for them. A person said, “The staff make sure I take my medication at the right time.”

There were suitable arrangements for ordering, storage and disposal, including for medicines needing cold storage and those requiring extra security. Temperature monitoring was carried out to ensure medicines would be safe and effective.

If medicines were prescribed to be taken ‘when required’ there were protocols in place to guide staff when these might be needed. We found a small number of protocols were not in place or up to date, the provider assured us these will be rectified. Records were in place to show that risks were assessed for people using higher-risk medicines such as anticoagulants, and flammable topical preparations.

Staff had regular training, and competency checks to make sure they gave medicines safely. Any errors or incidents were investigated and reported, so that systems could be put in place to prevent a recurrence. Regular medicines audits identified improvements that were needed, and corrective actions were recorded.