Avonmere 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 requires improvement. The service was in breach of legal regulation in relation to the ways people’s medicines were managed safely. At this assessment the rating has changed to 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 provider had a positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The provider made improvements to ensure reported concerns were investigated and actions taken to mitigate future risks. Staff documented accident, incident and safeguarding concerns and the provider’s systems enabled actions to be taken. Lessons were learnt and shared within the staff team. Staff told us they were kept updated and informed of changes relating to people. Staff told us communication was effective and learning was shared. A staff member told us, “The senior team keep us informed during supervisions, team meetings, on the app and at 1 to 1 meetings.” External agencies were notified of incidents and safeguarding concerns as required. For example, the Care Quality Commission (CQC) and the local authority safeguarding team.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Relatives confirmed an assessment took place before people moved to live permanently at the home, and care plans were based on this information. However, the service had not always identified the additional support people may need when they have capacity, for example to make decisions on how they wanted to receive their care. There were gaps in how essential care information was shared. This included when individuals independently arranged appointments such as with healthcare professionals as there was no clear process to ensure staff were informed of relevant risks, such as falls prevention. This posed a potential risk to the safety and effectiveness of care delivery.

During the assessment, senior staff liaised with the individuals involved and agreed on a process to ensure that key information was communicated appropriately. This ensured coordination of care and staff were equipped to support people safely while respecting their autonomy.

Staff told us if they noticed a person’s physical or mental health had deteriorated, they would inform senior staff and document any changes. They recognised this as their responsibility to highlight concerns and to continue to observe the person. Senior staff said they would contact external agencies, such as community nurses or GPs for advice, and we saw how they discussed what steps were needed to manage people’s risk.

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 provider shared concerns quickly and appropriately.

Since our last assessment, the service had made improvements to the systems and processes to make sure people were protected from abuse and neglect. There was a comprehensive safeguarding file, which contained details about the incidents and a description about what actions had been taken to minimise further risks. This included sharing the information with the local authority safeguarding team and updating the person’s care plan. The registered manager audited these to ensure all appropriate action had been taken to safeguard the person. The provider was notifying CQC of allegations of abuse in accordance with legislation.

Staff confirmed they knew what to do in the event of an allegation of abuse being made. All staff completed safeguarding training, which was refreshed annually. Staff were aware of the reporting process for allegations of abuse. Policies and procedures guided staff on what to do if an allegation of abuse was made and how staff could raise concerns using the whistle blowing policy.

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), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the service was working within the principles of the Mental Capacity Act (MCA) and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. The provider kept these under review and monitored them regularly. People’s capacity and the Deprivation of Liberty Safeguards (DoLS) in place were included in people’s care plans, including what the DoLS meant when supporting people. Where people required support to make decisions, staff documented this in people’s care records, including how decisions were made in people’s best interests.

The provider did not always work well with people to understand and manage risks. Systems were in place to identify, assess, and manage risks to people. Improvements had been made and sustained to manage risks related to people’s swallowing difficulties. Staff assessed these risks and monitored them for any changes in needs, with appropriate referrals made to the speech and language therapy team. However, we found some risk assessments were not sufficiently personalised, with individuals referred to as “the casualty” rather than by name. For example, care plans for people with epilepsy, diabetes, choking risks, or behavioural support needs included generic information, such as medication side effects and symptoms, rather than tailored details specific to the individual. As a result, we could not be assured that the information was accurate to support people safely and in line with their preferences and wishes. Despite this, people and their relatives told us they felt risks were sufficiently managed. Records showed care plans were regularly reviewed, and most people or their relatives told us they were involved in the process. One relative said, “The care plan is reviewed, and I can check it on Relish.” We observed a calm and supportive environment, where people were encouraged to move about the service independently. Staff knew people well and demonstrated an understanding of people’s risks. They told us care records were reviewed regularly and they had sufficient guidance on how to support people. A staff member said, “the deputy manager and senior carers review the care plans and update us during handover. For example, if someone has had a fall and we need to monitor them regularly or support them differently. The service encouraged people to take positive risks, such as administering their own medication, daytrips, swimming and assisting people to maintain their mobility. The provider responded promptly to update risk assessments where shortfalls were identified.

The provider did not always detect and control potential risks in the care environment. The provider had systems to detect and manage potential risks within the care environment. People using the service, their relatives, and staff told us they were satisfied with the service environment. However, we identified some shortfalls in the management of environmental risks which the provider had not identified as part of their governance processes. For example, information held in the emergency grab bag was not up to date for staff to use effectively in the event of an emergency. We raised these issues with the management team, and during the assessment the provider took prompt action to address them. The service had a dedicated member of staff responsible for overseeing maintenance. We found most areas of the service were clean and well maintained. Other documents we reviewed relating to fire safety and health and safety checks, were up to date.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider safely recruited staff. Senior staff conducted relevant employment checks before new staff started working at the service. This included criminal record and employment checks to confirm staff were safe to care for vulnerable people. The registered manager told us they had sufficient staff and used a dependency tool to assess staffing needs. Staff said the manager arranged agency cover when shifts were cancelled. However, while some felt the service was occasionally short staffed, they noted staff responded promptly. One resident said, “They’re very short staffed, especially in the morning, but my call bell is answered quickly.” Staff confirmed they manage well, even during busy times like mornings and meal periods, due to strong teamwork.

People were supported by staff who had an induction that included shadowing more experienced staff and ongoing training. Staff completed Formal competency checks on moving and handling and medicine administration to ensure they were confident in these areas. Staff new to care completed the Care Certificate as part of their induction. The senior management team monitored ongoing compliance to training and followed up with staff to ensure training was completed. Staff spoke positively about the training they had received. A member of staff told us, “The training is excellent, it gives me confidence in my work. After completing choking response training, I was able to act quickly when a resident began choking in the dining room. The paramedic said we saved their life.” Another member of staff told us they had completed lots of training. However, they would like more training on supporting people with dementia and palliative care.

Since the last inspection, there was an improvement in the way the care team worked together. There was also a better working atmosphere which benefited people living at the service. The staff team had stabilised, and the team told us they worked well together. Staff were responsive to people’s care needs and there was an improvement in staff interactions with people living at the home. Staff were less task focused in their approach and chatted with people which increased people’s well-being. Records showed the provider had addressed poor staff practice and taken disciplinary action, where necessary.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service was clean and free of malodours. People and their relatives told us the service was regularly cleaned. One person said, “it is clean – it never smells, it's tidy and clean”. Staff told us they used personal protective equipment (PPE) and senior staff checked their competence in using PPE regularly. A relative told us, “I have seen them wearing gloves when helping her”. The service’s infection prevention and control policy reflected national guidance. We were assured the provider was taking appropriate steps to protect people, staff, and visitors from the risk of infection.

At the last assessment improvements were required in the management of medicine. At this assessment, we found the service had made improvements in this area.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in medicine planning, including when medicine changes happened. The service had individual arrangements to make sure each person received their medicines appropriately and safely. The provider now kept clear records of all medicines received and administered to people. Records of administration were kept electronically ensuring all medicines were accounted for. Senior management monitored this remotely to ensure people received their medicines in a timely way. Senior managers completed regular audits of medicines and staff competence. When errors occurred, the audit identified and addressed them.

Staff had been trained in the safe handling, administration and disposal of medicines. Senior managers annually assessed staff who administered medicines. Training records and staff confirmed they had received training.Staff stored medicines securely and followed controlled drugs protocols. Staff took daily fridge temperatures to ensure the fridge remained at a safe temperature for storing medicines.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. People felt involved in their care and were supported with their medicines in ways that promoted their independence, dignity, and personal choice. They received their prescribed medicines as intended and were supported to self-administer or apply their medicines, including creams, where this was assessed as safe and appropriate. Staff recorded topical medicines appropriately, with clear body maps stored in people’s care plans to guide application. The provider had detailed guidance for 'as and when required' (PRN) medicines, such as pain relief. This included clear instructions on when and how to administer medicines based on individuals’ needs and behaviours.