Avebury House

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. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 proactive and 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.

Falls and near misses were recorded with clear details of what had happened, including what people were doing in the lead up to the fall, for example where people were or whether they were interacting with other people. This helped staff identify situations which could escalate people’s anxieties. Staff took a pro-active approach to prevent situations escalating where possible and minimise distress for people.

Incidents were reviewed by the management team to ensure actions were taken to reduce the risk of a repeated incident. Staff told us learning from incidents was shared with them and gave them clear information on any changes to the way they needed to support people. Comments from staff included, “Incidents are recorded and always reviewed and followed up by the management. They share findings with us in team meetings and supervision. Sometimes we will have additional training if needed.”

The provider 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.

Relatives told us the service worked well with health services people were using. People’s health conditions were documented, and they were supported to access services from a range of professionals including specialist nurses.

People we spoke to had lived in the service for up to a year. One relative we spoke to told us the local authority had placed a relative at the home. They told us they were concerned, given the previous regulatory history of the home, however praised leaders. Comments included: “[leaders] went and assessed my [relative] in hospital” and “the whole process from start to [relative being here] was handled professionally and sensitively by the provider”. The manager told us no-one was currently looking to move out of the service, however there was someone due to move in on the day of our assessment.

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.

Relatives said they felt people were safe living at the service and knew who they could talk to if they had any concerns. When asked, one relative told us, “Since the new management, I’m really impressed with how accessible and safe they have made the home.” We observed people who looked comfortable interacting with and in the company of staff.

Staff demonstrated a good understanding of their safeguarding responsibilities and said they completed regular safeguarding training. Staff were confident managers would take appropriate action if they reported safeguarding concerns. Staff were also aware how to raise these concerns outside of the organisation if they needed to. The service had a safeguarding tracker which ensured all actions were followed up. However, the registered manager did not always ensure that outcomes of investigations were documented and some of the information was missing. We spoke to the provider about this who made changes to the tracker.

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 provider had applied to the local authority for (DoLS) authorisations where appropriate. The registered manager had a record of all DoLS applications that had been made, including details of any conditions to the authorisations.

The provider did not always work with people to understand and manage risks by thinking holistically. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some guidance for people who had long term health conditions was not listed in care plans, for example people at risk of blood clots and who previously had a cancer diagnosis. Whilst there was no impact on the person, without guidance staff may not have been aware of the signs and symptoms to monitor or the action to take if concerns arose. This meant there was an increased risk that changes in people's health could go unrecognised or not be responded to promptly, placing people at risk of avoidable harm. Given the potential seriousness of these conditions, the level of risk was not appropriately mitigated.

We spoke to the provider who took immediate action to update risk plans and guidance for staff.

People we inspected under the right support, right care right culture guidance did not have clear positive behaviour support (PBS) plans. We expect providers to ensure autistic people and people with a learning disability to have person-centred PBS plans that identify the reasons for behaviours of concern, proactive strategies to reduce distress, and clear guidance for staff on how to respond consistently. For example, one person had limited communication, and another two did not communicate verbally. Without communication and behaviour support information, there was a risk people would not receive support tailored to their individual needs, preferences and communication styles, which could negatively impact their wellbeing, choice, control and quality of life.

We observed one person trying to communicate their needs to staff. This demonstrated the potential impact of the missing guidance, as staff may not have consistently understood or responded to the person's communication in the way they preferred. We were not assured staff had access to sufficient information to provide individualise support consistently, which meant risks to people's wellbeing and opportunities for meaningful involvement in decisions about their care were not fully mitigated.

The registered manager assured us they would review the documentation available for autistic people and people with learning disabilities.

Staff demonstrated a good understanding of most of the risks people faced and how to support them safely. Staff told us, and we saw in the records, that risk management plans were regularly reviewed and updated as people’s needs changed to ensure information was accurate. We observed staff following the risk management plans throughout the visit. This included risks related to fire and flammable based emollients.

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

At the previous assessment, the risk of fire was not adequately managed. At this assessment, fire systems and fire doors had been upgraded to comply with safety regulations.

The provider completed various health and safety checks to make sure the premises, and any equipment was safe. The provider had a legionella risk assessment and water samples were regularly tested to ensure they were safe. Equipment was serviced regularly and staff completed regular checks of the environment to identify any shortfalls.

Relatives told us the home was well maintained, with comments including, “I love what the [registered manager] has done with the upstairs floor.” People told us: “Since the new manager has been here, they have sorted out the garden, we had a meeting and were asked what we wanted, a lot of us said we’d like to sit out and see the canal – they listened to us and they did this.” Leaders confirmed they had an action plan in place to address some areas of the home and had already made significant progress in upgrading the home for people. The registered manager told us they had focused on the environment as this was the most important for people receiving a service. During our assessment we saw leaders had requested additional funds from the provider to ensure the environment was safe, well maintained and met people’s individual needs. This had led to improvements being made across the home, including the refurbishment of communal areas and replacement of worn furnishings, helping to create a more comfortable, accessible and homely environment for people. People had a cinema room where vintage movies were screened. The registered manager told us this was well received by people, especially people who were living with dementia.

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.

Relatives told us there were enough staff available to meet people’s needs. Comments included, “There is always a member of staff available for me.” Relatives confirmed the staff team was stable. The provider confirmed they actively employed over their staffing number requirements. Staff told us staffing levels were sufficient to meet people’s needs. Comments included, “It feels like there are enough staff on each shift.”

Staff told us they received a good induction when they started working in the service and regular training. Staff said the training was a mix of in-person and online courses, which gave them the skills and knowledge to meet people’s needs. Staff were supported to complete relevant training including communication and dementia. Managers had a record of training staff had completed and when any refresher training was due.

However, while staff had received specialist training in autism and learning disabilities, they had not undertaken training relevant to the Oliver McGowan or equivalent code of practice. This meant they may not have had the knowledge and skills required to fully understand and respond to people's individual needs, preferences and communication styles. During the inspection, the registered manager applied to have “learning disabilities” added to their registration. Leaders said they would consider employing a designated learning disabilities lead, to better understand CQC’s expectations around Right Support, Right Care, Right Culture.

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.

All areas of the service were frequently cleaned and well maintained. Staff had appropriate access to personal protective equipment and had received training on infection prevention and control good practice. Staff told us they had all the equipment they needed and received suitable training. We observed staff following good infection control practice.

The management team completed regular infection prevention and control audits, which included an assessment of how staff put their training into practice and spot checks.

There was some malodour in some areas of the home. The registered manager told us this had been identified and showed us a plan for ensuring carpets were changed for hard flooring. During our assessment, the new flooring was delivered.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored safely, in air-conditioned medicines offices. The temperature of the medicine fridge was being recorded daily.

Medicines administration records had been fully completed, with details of medicines people were supported to take. Staff received training in medicines management and records demonstrated there were regular checks for their competence in administering medicines safely.

The provider was not signed up to STOMP (Stopping over medication of people with a learning disability and autistic people). This is a national initiative to stop over prescribing of psychotropic medicines, however people with a learning disability had been supported to attend regular medication reviews with the GP.