Averill House

Updated 1 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors, a medicines inspector and an Expert by Experience carried out this inspection.

An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Averill House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Averill House] is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new ‘turnaround’ manager had been in post for one month and had submitted an application to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 7 people who used the service and 3 relatives about their experience of the care provided at the home. We spoke with 12 members of staff including the manager, deputy manager, area director, regional quality improvement lead, care assistants, and the chef. We also spoke with 3 visiting professionals.

We reviewed a range of records, including 4 people’s care records and multiple medication records. We looked at 2 staff files in relation to recruitment. We looked at a variety of records relating to the management of the service, including quality assurance and incident reports.

We observed the support provided throughout our inspection and viewed the environment of the home.

Updated 1 August 2023

About the service

Averill House is a nursing and residential care home providing personal and nursing care to up to 48 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 47 people using the service.

Averill House is a purpose-built care property with 3 floors. The ground floor provides residential support, and the first floor provides nursing care. Each floor has two lounges, dining room and adapted bathing facilities. The third floor has a large kitchen and laundry.

People’s experience of using this service and what we found

Medicines were not always safely managed. The home took actions to rectify the issues we found following our inspection. A quality assurance system was in place and actions completed for any issues identified. However, the medicines audits had not been robust in identifying the issues we found during this inspection.

People felt safe living at Averill House. Risks were identified and guidance was in place to manage them. There were enough staff to meet people’s care and support needs. Staff were safely recruited. Equipment was regularly checked and serviced in line with legal guidelines. Incidents and accidents were reviewed for any learning to reduce further occurrences. The home was clean throughout, and infection control was well managed.

Staff said the management team were visible in the home and approachable if they needed to speak with them. The home worked well with a range of professionals, including physiotherapists, GPs and district nurses.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and relatives said they were involved in agreeing and reviewing their care plans. Relatives said there was good communication with the staff team and any concerns they had were addressed. Staff said they enjoyed working at the home.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 20 December 2018).

Why we inspected

We received concerns in relation to the management of medicines and people’s nursing care needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report. Action had been taken to address the issues we identified.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Averill House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to the safe management of medicines at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.