Avon Lee Lodge

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 remained at good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. However, improvements were needed regarding the governance processes concerning lessons learned.
Incidents and accidents were recorded, reviewed by the registered manager and discussed with the staff team to prevent reoccurrence. However, we identified the system used to review and analyse accidents and incidents and promote learning from such events was not always effective and lacked detail. We discussed our findings with the management team, who, during the inspection, showed us an independent software package that was going to be implemented immediately following the inspection. The registered manager told us, “We do understand how we can use our systems better.” The package would provide an improved system for reviewing themes and trends of incidents and accidents within the service.
People and relatives provided positive views on the care and support given by staff. One relative told us, “[Relative] had a couple of falls and had to go to hospital but they let me know straightaway and they have done everything now to keep them safe, they do everything very well.” The management team discussed a variety of incidents that had happened and how learning from these incidents had been shared with the staff team during supervision sessions and team meetings. They told us, “We identified incidents around the management of day and night-time staff. We reviewed the situation in order to get both teams to work together so people get the best care. We always address any incidents or concerns right at the start so we can manage the risks and ensure people are safe. We make continual changes to ensure people are kept safe.”

The service 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.

We spoke with a visiting health and social care professional who gave complimentary views on all aspects of working with the service. They told us, “We visit this service approximately once a week. We all work well together. They always let us know if there any issues or health concerns and they are very responsive. They send me a list so I can review what is needed. People are very happy here, they are well cared for and always well presented. Staff are happy in their roles. I have no concerns at all, they work well with me and ensure all our information is up to date and accurate, they are very responsive.”

Staff told us they had enough information to ensure people maintained their health and received effective care and support. A member of staff said, “The risk assessments are clear and care plans give enough information for us to care for people well. We know people well, the information is detailed. We provide really lovely care to people. We are listened to; we are a good team.”

The management team had implemented the use of an independent virtual clinical tool provided by the local medical practice. The tool used an independent video link where the nurses at the medical practicecould view wounds, a person’s demeanour, any new medical issues and triage each situation. These would then be passed to the relevant medical professional such as the GP or the practice nurse to action, saving time and resource and providing effective, responsive care for people.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

People told us they felt safe living at Avon Lee Lodge and enjoyed living there. One person told us, “Oh yes I’m very safe here.” A relative told us, “[Person] is safe. I’m kept informed through messaging or we use the portal to check what’s happening, the portal works well. They look after people with care, compassion and empathy, they support me as well.”

Staff received safeguarding training and spoke knowledgably about different types of abuse and how they would recognise and report any concerns. Staff were confident in reporting any potential abuse, a member of staff said “I would go direct to my line manager or the registered manager or both, I would always pass any information on. We document everything to make sure people are safe.” There were policies in place that covered safeguarding and whistleblowing. These gave staff guidance to follow if they needed to refer any concerns. Safeguarding referrals had been made as necessary, including notifying CQC of specific events as required. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Relatives told us staff involved and consulted them in regard to how they received their care and support to ensure their safety. A relative told us, “They definitely keep me involved, all the time. I’m perfectly happy and [person] is happy that is the main thing, she is safe. They know [person] well and care for [person] well.” Another relative said “I have no concerns, [person] is very, very happy at Avon Lee Lodge, they have been there about a year. They know [person] well and absolutely treat them as they would like, they always keep me involved and informed if anything happens.”

Staff spoke knowledgably regarding how people preferred their care and support to be given. A member of staff told us, “The risk assessments are clear and care plans give enough information to care for people. We know people well, the information is detailed and people, if they can the person will tell us how they like their care to be delivered. For example, if someone has diabetes and is insulin dependent and has other underlying health conditions, we monitor all their observations, blood sugars, heart, temperature etc, these give a good indication how people are and allow us to act quickly if needed.”

Staff were seen to provide gentle encouragement and prompting to ensure people remained safe during our onsite visit. People appeared comfortable with staff and actively sought them out for a chat and to spend time with.

Risks to people were individually assessed and regularly reviewed. Risk assessments were personalised, detailed and gave staff clear guidance on ensuring people were supported safely, whilst still maintaining their independence. Risk assessments covered all areas of potential risk including to people and the environment. Emergency plans were in place to ensure people received the support they needed in the event of a fire or other adverse event.

The service detected and controlled potential risk in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment provided opportunities for people to access communal areas, private areas and had an accessible outside space. The service met the needs of people and allowed them to move around the service safely. Corridors provided hand rails and were light and airy allowing people to move around the service without restriction. We asked a member of staff their views on the environment of the service, they said, “I think there is always room for improvement, on the whole it is pretty good. If anything gets broken it gets replaced quickly. We have a maintenance person who is through. When an alert pendent was broken they fixed it straight away.” Staff received training in using the equipment and spoke knowledgably regarding all the types of equipment they used. A relative told us, “The environment here is nice. It’s clean and bright and cleaning is done thoroughly every day.” Another relative said, “Any equipment [person] needs, they get.”

Equipment and utility checks were completed to ensure safety. The service had a dedicated maintenance member of staff and domestic staff for cleaning purposes.

The service 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.

There were adequate numbers of staff available on each shift to ensure people were cared for safely. Staffing rotas reflected people were cared for by appropriate numbers of staff. The service calculated the numbers of staff needed on each shift in accordance with people’s health needs, this ensured people were provided with safe care. There was a stable staff team with some staff having worked at Avon Lee Lodge for many years. This meant people received consistent care and support from staff who knew them and their care needs well. There were enough staff on duty to ensure people's safety. A member of staff told us, “We constantly do training, all the mandatory courses, it all makes sense and we are constantly refreshing our knowledge. We have an in-house trainer and practical face to face training such as fire awareness and first aid. We get good training with a consistent trainer.” People and their relatives told us there were enough staff on each shift to provide safe care. A relative told us, "There are enough staff on shift to care for [person]. I know a good proportion of them, there is not much staff turnover so I’ve got to know them and it makes a difference when we know them by name.” Recruitment records showed staff were recruited safely. Procedures were in place to ensure the required checks were carried out on staff before they commenced their employment at Avon Lee Lodge. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff received mandatory training through a mixture of practical face to face training and on-line courses. Staff felt well-supported by the management team and received supervision sessions which they stated were helpful. During the inspection, we observed staff responding promptly to people's needs and did not appear rushed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. During our site visit, oversight of infection, prevention and control measures were not always effective. Records confirming cleaning had taken place had not always been completed, and there were a number of discrepancies identified by inspectors in the most recent infection prevention control audit. For example, the audit stated that all waste bins were pedal lid however we observed gloves placed in open wastepaper bins in corridors. Following a discussion with the leadership team, we were assured people were protected from avoidable risks from infection as staff had completed infection control training, and people and their relatives told us the service was clean and uncluttered. Management of the service assured us that new equipment would be ordered. The service had a dedicated cleaning team and personal protective equipment (PPE) was worn appropriately by staff. Staff had appropriate supplies of cleaning materials, products, and PPE. A member of staff told us, “We have enough PPE, we use gloves, aprons, face masks and there are always enough hand gels all around. We are all trained in infection prevention and control. We have 2 dedicated staff.”

The service had not always ensured that medicines, treatment and medicine systems were managed safely and met people’s needs, capabilities and preferences.

Audits were completed for medicine management, however, the medicine audits did not always identify the shortfalls we identified during the inspection. These shortfalls had not resulted in any harm to people. Shortfalls included the completion of MAR and “medicine as required” processes. There was not an “as required” (PRN) protocol process in place, or guidance for staff on what steps to take regarding PRN medicine. When people were prescribed additional medicines on a PRN basis, there was not sufficient guidance for staff on what steps to take regarding the PRN medicine. We discussed our findings with the registered manager who confirmed they would ensure future medicine management processes would follow the National Institute for Health and Care Excellence guidance. Staff who administered medicines had received up to date training and had their competency checked regularly. Systems were in place to order, store, administer, record and dispose of medicines. Medicine Administration Records (MAR) were all signed to indicate people had received their medicines as prescribed. Body maps had been completed for people indicating where topical creams and pain-relieving patches needed to be applied. The medicine room temperatures were recorded daily and medicines were stored safely within the required temperature to ensure their efficacy.