Averley Home

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• 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 service under the new provider. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of the legal regulations relating to safe care and treatment and staffing.

This service scored 56 (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. Lessons were not always learnt to continually identify and embed good practice.

Staff knew how to report any accident, incident or safety concerns. These were reviewed by the management team. There had been a minimal amount of these events so no specific patterns or trends had been identified. Staff gave an example of how one person’s actions whilst in their bed were potentially dangerous. They detailed what steps had been taken to ensure this did not result in an accident.

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.

There were effective systems to share information with other services to ensure people received consistent support. Key information about people was contained in their care plans. People also had hospital passports to support people when they needed to go to hospital or attend clinic appointments. These records contained all the necessary information for external professionals to know about the person’s health and communication.

Systems were in operation to ensure staff had up to date information about people. These included a verbal handover at the beginning of every shift. Relatives told us they received regular communication with the service about any changes in their family member’s needs. This helped to ensure people received consistent support when they spend time with their family members. One relative told us, “When she comes to me, she always wants to go back to Welcome Home (Previous name of Averley Home).”

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 staff training matrix recorded that all but one staff member had received training in how to recognise and report abuse. The registered manager told us this staff member had completed this training with another provider and never worked alone. Staff we spoke with knew to report any concerns to a member of the management team and how to whistle blow. This is where staff are protected if they raise concerns internally. Staff also knew how to report to external agencies should they not be listened to. The registered manager understood how to report safeguarding concerns to the local authority who is the lead agency for safeguarding. A staff member told us, “If I had any concerns I would let the manager know. And if they did not take action, I’d let CQC or the local authority know.”

We observed staff interacting and supporting people to maintain their safety. Staff provided people with assistance who required it, to move around their home. Relatives told us their family members were safe living at the service. One relative told us, “He is absolutely safe.”

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). We checked how they managed DoLS within the service. It took some time to establish that DoLS applications had been submitted appropriately as monitoring records were not up to date. The provider was aware of and complied with any conditions attached to authorisations.

The provider did not work well with people to understand and manage risks. Staff 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.

People’s care and support records contained a range of risk assessments relating to their health and social care. These included enabling people to go out, eat their meals safely and move around their home. Staff were not always following guidance that set out the steps they needed to take, to keep people safe. Some people had epileptic seizures which could occur during the day and night. Their care plan set out it was important for staff to be aware when the person was having a seizure so a monitor alert had been placed on their bed. There is a higher risk that people with epilepsy can have sudden unexpected death during sleep (SUDEP). However, not all staff were aware that a person had an alert monitor on their bed so they were not consistently using it.
There was a risk that with no staff assistance the person would not be kept safe nor would emergency assistance or rescue medication be provided as needed. The registered manager confirmed that after this had been brought to their attention they provided face to face training with day and night staff about how to use the monitor.

Each person had a personalised evacuation plan with guidance for staff and emergency services on the support they would need to evacuate the building safely in the event of a fire. However, the last time a fire drill had been carried out with night staff was 18 months previously on 23 September 2024. Staff told us people’s mobility had deteriorated in the last year. Therefore, the provider could not be assured staff were competent in safely evacuating people from the service at night time in a timely manner. The provider gave assurance a night time fire drill had been completed after the inspection visit. One person who used a wheelchair to mobilise in the event of a fire had a fire escape in their room. However, the ramp they used to evacuate was wooden and in need of repair. There was a portable kit of essential items for staff to grab by the front door in the event of a fire.

Risks relating to the management of constipation were well managed. NHS England has highlighted that people with a learning disability are at significantly higher risk of constipation than the general population. Staff made record of people’s bowel movements and these were monitored by a dedicated staff member to alert staff if people required prescribed medication.

The provider did not always have effective systems to detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had not ensured the environment had been adequately maintained to ensure people’s safety and to meet their needs. Although the provider had been responsible for the service for 10 months, they only put together a plan of works needed, the day before our inspection visit. This included plaster coming off the walls, the front door ramp having gaps in the paving and the handrail not being secure, and some people’s showers not draining properly. The plan of works did not include estimated dates of completion. These dates were added during our assessment. During the assessment the provider confirmed the kitchen, which was worn, had been replaced.

Regular servicing of equipment had taken place such as the maintenance of gas, water and electricity supplies. Regular checks and maintenance were carried out of fire fire-fighting equipment.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Staff had not completed all the training they required to ensure they had the skills to support the people in their care. Some people had specialist needs such a receiving food and medicines by a tube which passes directly into their stomach called a percutaneous endoscopic gastrostomy (PEG). In additional some people needed specialist rescue medication when they experienced a seizure. The provider did not give assurances staff were skilled and competent with this tasks.

Staff were made aware of the complex risks in supporting a person using a PEG in their care plan. This included identifying infections and tube blockages. Staff told us they contacted the PEG supplier if they had any concerns and that they had done so recently. However, the training record evidenced that only 4 members of the staff team had received training in PEG feeding. The staff member administering the PEG on the day of the assessment visit was not on this staff training list. The registered manager told us there had been no assessment of staff competency in using a PEG for staff who did not have recent training. During the assessment training was booked for all staff to ensure they had the skills to support people safely, once this had been brought to their attention.

Some people required specialist rescue medication after they had experienced a seizure called buccal midazolam. The Epilepsy Nurses Association (ESNA) recommends that professional carers of people with epilepsy should receive refresher training in administering this medication, 2 yearly as a minimum. The training matrix recorded that 2 staff had last attended training on 7 and 11 March 2024. These 2 staff were overdue for their refresher training but this had not been highlighted on the training matrix. The provider changed the cycle of this refresher training to 2 yearly when the local authority had brought to their attention.

The staff training matrix identified that one staff member had been enrolled on a range of courses, but they had not completed any. The registered manager told us they had completed the courses with another provider but had not assessed their competency to ensure they had the skills and knowledge required in these areas.

Staff told us there were not enough of them available to ensure people led fulfilling lives. They said that people’s mobility needs had deteriorated in the last year which meant they needed additional staff when going out. One person had not been able to regularly attend an exercise session to maintain their mobility. Staff also told us staff had retired and left and not been replaced and that there were a limited number of qualified drivers. Where there were gaps in minimum staffing levels, agency staff who had previously worked at the service were employed. The provider acknowledged that people’s needs had changed and had contacted the funding authority with regards to one person. However, they had yet to formally reassess people’s dependency needs to ensure there were sufficient staff available to meet their changed needs. When the provider carried out their dependency tool during the assessment, they identified there were not sufficient staff to meet people’s needs. The funding authority was reviewing people’s needs at the time of the assessment.

New staff completed an induction, including shadowing experienced staff and undertaking training. The provider’s policy set out that new staff should only be permanently employed once they had successfully completed a probationary period. However, probationary forms had not been completed to check staff were competent to support people at the service.

Although staff said they felt supported there was no formal supervision nor staff development programme in place. The registered manager informed us during the assessment that future supervision sessions had been planned with the staff team.

The provider had not always followed their recruitment policy. They had not always checked the reasons for any gaps in people’s employment history. All other checks had been undertaken to ensure safe recruitment. This included obtaining work references, people’s employment history and Disclosure and Barring checks (DBS). 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 provider assessed and managed the risk of infection.

The provider had systems and processes in place to assess and manage the risk of infection. Staff had received infection prevention and control training and understood what to do to mitigate infection risks.

Cleaning was difficult in some areas but the service was clean on the day of our assessment. A housekeeper was employed and care staff undertook cleaning as needed. Staff also supported people to clean their rooms.

We saw supplies of personal protective equipment (PPE) such as gloves and aprons situated around the service, to provide safe care. We observed staff using PPE appropriately. Relatives said the service was clean when they visited.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People had been assessed as not able to manage their own medicines and therefore were reliant on staff to do this for them safely. People’s medicines were kept securely in their rooms. However, for one person, two of their medicines had been taken out of their original box and placed in another container. The Royal Pharmaceutical Society (RPS) has defined secondary dispensing as ‘re-packaging a medicine that has already been dispensed by a pharmacist or a dispensing doctor’. This is not best practice as it removes vital safety checks and increases the risk of errors. The provider confirmed during our assessment that this person’s medicines would not be removed from the boxes they were in when dispensed from the pharmacist going forward.

There were some shortfalls in the management of medicines which were prescribed to be taken when and as needed (PRN). A record was made when these people’s medicines were taken out of the service with them and when they were returned. For one person the records showed that they had not left the service at all in January 2026 and only 3 times in February 2026. The registered manager told us this person had gone out more frequently than these records indicated. This indicated that staff were inconsistently recording when medicines left the service, which increases the risk of stock errors. One person did not have a PRN protocol for one of their medicines. This was put in place during the site visit. The provider’s medicines audit had not identified these shortfalls in medicines management.

Medicines administration records had been completed accurately. There was clear guidance for people who required their medicines to be administered through a PEG tube. Professional advice had been sought when one person regularly started to spit out their medicines so they were not as effective as intended.