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Inspection Summary

Overall summary & rating


Updated 21 December 2018

The inspection took place on 13 and 14 November 2018 and was unannounced.

The last inspection of this service was on 12 and 13 September 2017 where we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as the provider had not assessed the risks behaviours posed to other people. Following the inspection, we asked the provider to take action and told the home to produce an action plan to address the issue we had found. At this inspection, we found there were improvements to risk assessments to mitigate the risks behaviours posed to others. Further information can be found in the body of the report.

Averill House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Averill House is a modern purpose-built property which can accommodate up to 48 people. There were 44 people living at the home on the dates of inspection. The home is divided into three floors. People are supported on the ground and first floor and a large kitchen and laundry facilities are situated on the third floor.

The service had a registered manager in place. A registered manager is a person who has registered with CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was supported by a deputy manager, both managers assisted with the inspection.

People felt safe living at Averill House and were aware of how to raise any concerns they had. Staff members were aware of their responsibilities in relation to protecting vulnerable adults from abuse and were confident the registered or deputy manager would act on any concerns they had. All staff had received safeguarding training.

Staff members were recruited safely and received a robust induction to introduce them to their role. Staff received regular supervision and attended staff meetings to ensure they were kept up to date with changes and had the support to carry out their role effectively.

Premises safety was well managed. Regular external checks took place of equipment such as the firefighting systems, the passenger lift, moving and handling equipment and electrical and gas safety. Internal checks on premises safety were completed weekly or monthly and clearly documented.

People had appropriate risk assessments in place to support them. Risk assessments were reviewed regularly or when needs changed. They identified strategies to support people to minimise risk.

Accidents and incidents were fully documented, and lessons learned were shared to prevent future occurrences.

Medicines were safely managed. Audits were in place to monitor the safe receipt, storage, administration and documentation of medicines. Staff received training to enable them to administer medicines safely.

Staff received training suitable for their job role. The provider supported staff to complete diplomas in health and social care to expand their knowledge. We saw all staff received an induction and were given the opportunity to shadow more experienced members of staff.

The service was working in line with the Mental Capacity Act 2005. People received appropriate capacity assessments and decisions were made in people’s best interests. People were only deprived of their liberty where applications had been made to do so.

People were supported to eat a healthy and nutritious diet. People were very complimentary of the food and were supported to eat a diet from their cultural background should they wish.

People received input from primary care services such as a GP or dentist. The service was part of a project to enable people in the home to be diagnosed and treated promptly. The project was working to reduce admissions to hospital and involved weekly reviews of peoples health.

We observed caring and dignified interactions between staff members and people living at the home. People told us they felt cared for and staff always ensured their privacy and dignity and encouraged independence.

Care plans captured people’s support needs and were person centred. People told us they had been able to contribute to their care plan and we saw people’s choices, likes and dislikes were clearly recorded. Care plans were regularly reviewed to ensure they were current.

Activities were varied, and people were supported to attend social groups and one person was supported to enable them to meet people from their own culture.

People were supported to remain at the home at the end of their life. The service worked with district nurses and other professionals to ensure people were supported to be pain free and had their choices respected at the end of life.

Audits to monitor and improve the service were in place. Audits worked to highlight areas for improvements and action plans were then developed to ensure the improvements were made in a timely manner.

People and staff members told us they felt well supported by the registered manager. We observed the registered manager was visible across the home throughout the inspection, and offering support to people, staff and relatives. The registered manager felt well supported by the area manager.

Inspection areas



Updated 21 December 2018

The service was safe.

Risk assessments highlighted the risks people presented and gave detailed strategies to reduce the level of risk to the person and others.

Robust recruitment procedures were in place to ensure staff were recruited safely.

Staff had received training in protecting vulnerable people from abuse and could describe actions to take should they suspect abuse was occurring.



Updated 21 December 2018

The service was effective.

Staff received the training and supervision required to enable them to carry out their job role effectively.

The service complied with the requirements of the Mental Capacity Act and people had their capacity assessed and any referrals made to deprive people of their liberty were made to the local authority in a timely manner.

People were supported to receive a nutritious diet and people could choose to receive a diet from their own culture.



Updated 21 December 2018

The service was caring.

There were caring, kind and dignified interactions between staff at the home and people who lived there.

People were supported to remain as independent as possible.

Peoples personal information was stored confidentially.



Updated 21 December 2018

The service was responsive.

There was a varied programme of activities, people could choose to join in with. Activities took into consideration those who may want to network with people from their own culture and the service supported people to access community groups.

Care plans identified the support people needed. Care plans were formulated with people and their representatives and regularly reviewed.

Complaints were investigated and responded to promptly and outcomes shared.



Updated 21 December 2018

The service was well-led.

People, relatives and staff were complimentary about the registered manager and felt they had improved the home.

The registered manager was visible across the service and had oversight and governance systems in place to monitor and improve the home.

Notifications to the Care Quality Commission were submitted as required and the service displayed its current rating which are legal requirements.