Avalon Park Care Home

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 changed to 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 service was in breach of legal regulations 11 and 12 in relation to need for consent and safe care and treatment. 

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.

Where people had an accident or incident, this was recorded, monitored and action taken to address concerns. Analysis of incidents was also undertaken so that any trends could be monitored.

The management team regularly analysed accidents and incidents to identify any emerging themes or patterns in order to improve the care provided. These findings were then shared with the staff team. Staff confirmed they were informed of any actions following an accident or incident through daily meetings that took place. Any concerns about a person’s safety could be discussed during staff handovers.

The service worked in partnership with other professionals such as GP's and dietitians to support people to access healthcare when they needed it. This had improved people's outcomes. The management team and staff demonstrated how when a person's needs had changed, they had promptly engaged with several services to ensure the person's needs were fully met and understood.

‘Moving in’ assessments were completed when people first moved into Avalon Park so that staff could determine the level of care they required.

People living at the home and their relatives said the home was safe. One person said, “The staff are very kind and I feel very safe living here.” A relative also told us, “The staff are very good and (person) is very safe.”

There was a safeguarding policy and procedure in place which was in date and provided an overview about what people could do if they experienced any abuse. A safeguarding log was maintained, with details about any incidents reported to the local authority for further review. Staff had completed safeguarding training, which was documented on the training matrix and understood how to report concerns.

DoLS (Deprivation of Liberty Safeguards) applications were made to the local authority as required where people lacked the capacity to make their own decisions.

MCA (Mental Capacity Act) assessments were completed for certain decisions including living at Avalon Park, photographs, lap belts and sensor mats in people’s bedrooms.

We noted the only people involved in this decision making had been the person living at the home (who lacked capacity) and the previous home manager, meaning we were unable to determine these decisions were taken in people’s best interest. Reviews of capacity assessments had not been completed since 2023, so had not been completed by management at the time of our assessment.

This meant there was a breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding need for consent.

Each person living at the home had a series of risk assessments in their care plan which covered skin integrity, choking, falls and nutrition/hydration. These contained details about how any risks presented to people could be prevented.

Risk assessments weren’t always updated when people’s needs changed. For example, in care plans we saw references to certain equipment or nutritional supplements, but were informed these were no longer required. Some people’s care plan information contained contradictory information about how frequently they needed to be re-positioned to prevent the risk of skin breakdown. The registered manager said all risks assessments were to be reviewed and updated.

The building was safe and we viewed certificates of maintenance work completed around the home. External windows were all fitted with window restrictors to ensure people would not be able to fall from them, or leave the home in an unsafe way. Radiators were fitted with guards to ensure they would not become too hot and present the risk of burns and scalds.

Some parts of the living environment appeared ‘unhomely’, particularly the upstairs memory unit, where care was provided for people with dementia. Bedroom doors did not contain any names, numbers or memorable information for people to be able to relate to and find their room safely. The registered manager said this was something they were looking to develop further.

Staffing rotas were in place and this demonstrated how many staff were available to care for people. A dependency tool was used to determine how many staff were required.

Most people we spoke with told us more staff were required at the home. One person said, “The home have lost a lot of good staff and I feel more are required. They seem busy and don’t seem to be able to get through everything they need to do.” Another person said, “They need more, especially at night; staff seem so busy.”

Staff also voiced their concerns to us about staffing levels at the home. One staff member said, “There are not enough staff members. It is very difficult for staff downstairs currently. There are always lots of tasks that cannot get done and staff rarely take a break.” Another member of staff said, “We use too many agency staff. “Sometimes I am on shift with 2 agency staff, this is really difficult, and can often feel like 3 times the amount of work for the permanent member of staff.” A third member of staff added, “There are not enough staff in the service to support people well.” 

Staff were recruited safely with the necessary pre-employment checks carried out. Staff received regular training, supervision and appraisal to support them in their role. Staff said told us they received enough training to support them in their role, with a training matrix in place showing which courses had been completed.

Appropriate systems were not always in place regarding infection control. We found some areas of the home to be unclean including stained walls and armchairs in lounge areas. We were told arrangements had been made for these to be replaced, although we observed people still seated on them during the assessment.

This meant there was a breach of regulation 12 (2) (h) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding safe care and treatment.

An infection control policy and procedure and cleaning schedules were in place. Staff had completed infection control training, although this was due to expire for certain staff shortly and was due for renewal.

When people had their medicines covertly, hidden in food or drink, staff did not always follow the guidance provided. There was a risk they might not be given safely.

When people had their drinks thickened to prevent choking, staff knew how to prepare the drinks correctly, however there was not always records to show drinks had been thickened. The provider took prompt action to address this.

When people were prescribed ‘when required’ medicines, information to support staff to know when to give the medicines was not always person centred, and at times was contradictory. There was a risk people might not get their medicines when they needed them.

We found records for medicines that had additional recording requirements were not always accurate. This had not been identified by the service. However, we were assured people had been given their medicines as prescribed.

This meant there was a breach of regulation 12 (2) (g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding safe care and treatment.

When medicines had a shortened expiry date after opening, the date the medicine was opened was recorded. The manager completed audits to identify areas for improvement. The audits showed there was still work to do, however, improvements had been made. Shortfalls identified were shared with staff to drive forward the improvement needed.

Staff completed medicines training and had their competency assessed. When an incident or error occurred, the incident was investigated and appropriate was action taken.