Archived: Avon Lodge and Avon Lodge Annex

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

We identified 2 continued breaches of regulations. Firstly, we found a continued breach in respect of the provision of safe care and treatment. Secondly, we found a continued breach in respect of good governance; the provider’s and manager’s oversight had not been sufficient or effective in addressing the breaches of regulations and the issues raised at the previous inspection. Learning had not always taken place effectively as some issues identified at the previous inspection remained at this inspection. Processes and procedures implemented to support the learning culture of the service had not been effective. Support plans and risk assessments were not always in place around key risks to people including health conditions and needs. People’s health needs were not robustly managed, and this had an impact on their wellbeing. Staff and leaders had failed to identify areas of risk and the lack of support plans and actions in those areas, despite these concerns being raised at the previous inspection. There were enough staff to support people. Staff had received a good range of relevant training and compliance was good. However, the training was not always effective. Issues were identified during the assessment in areas where staff had received training, such as Mental Capacity Act documentation and procedures, and the safe management of food and fluids. A recruitment policy was in place. Where gaps were identified in previously recruited staff files, risk assessments were now in place. Improvements had been made from the last inspection in relation to medicine management, and medicines were now handled and recorded safely. The provider informed us there had been no recent safeguarding concerns so we were not able to assess how these would be managed. Some improvements had been made in respect of the premises and the service was largely clean and tidy.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People using the service appeared settled and content. We saw and heard nothing to indicate people did not feel safe, or that they would not be comfortable to raise any concerns. One relative told us, “[Person] is smiling more now.” There had not been any accidents or incidents for people to tell us about so that we could see how these were dealt with. There was easy read information available to help support people raise concerns if needed. However, although people appeared content, their actual experiences evidenced that the service had not made improvements in some areas which were specifically relevant to people's ongoing safety and wellbeing. Learning had not occurred around key risks to people, and this directly impacted people's experiences.

Staff told us improvements had been made following the previous inspection, and staff shared information immediately following incidents as part of a handover. However, we identified many of the same issues highlighted at the previous inspection remained present at this assessment, and there was limited evidence that any learning by staff had been effective. There was no evidence of a learning culture becoming embedded within the staff team.

Processes and procedures implemented to support the learning culture of the service had not been effective. Some of the issues identified at the previous inspection remained at this assessment and had not been resolved. New issues were identified in respect of the provider's failure to comply with the 'Right support, right care, right culture guidance'. Quality assurance audits had not identified the issues we identified during the assessment. Despite ongoing enforcement action following the previous inspection, there was insufficient evidence of learning from those findings and sufficient improvements had not been made.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives told us they thought people were safe. People appeared settled and content and where we were able to obtain feedback, people told us they were happy. However, people's actual experience was that areas of risk and concern were not appropriately managed by the service.

Staff had received safeguarding training and told us they knew what to do if they had any safeguarding concerns. However, staff had not identified or raised potential safeguarding concerns that we identified during the assessment. Staff had not acted on key risks to people, some of which had been identified during the previous inspection.

Safeguarding as a topic was discussed in staff appraisals and staff meetings. An appropriate safeguarding policy was in place. The provider informed us there had been no recent safeguarding concerns so we were not able to assess how these would be managed.

Although people appeared settled and content, risks to people were not appropriately managed. There was insufficient information and guidance for staff, and a lack of appropriate and effective plans in place, to manage people's medical conditions and key risks to people's health and wellbeing. This directly impacted people's experience of care. People were not always effectively involved in managing risk, and effective communication with people was not always in place.

Staff and leaders had failed to identify areas of risk and lack of support plans and actions in those areas. This was despite many of these concerns being raised at the previous inspection. Staff and leaders spoke about risk now being managed, however we found this was not the case. We found restrictions being used for 2 people who were unable to come and go from the service freely without asking staff. Documentation in place around this restraint was insufficient and this had not been identified by staff and leaders.

We observed risks to the environment generally being managed safely. We did not observe that risks to people's weight and people's ongoing health conditions were being managed robustly. We observed the front and back doors being locked which meant that people were not able to come and go from the service without asking staff. There was not always appropriate justification or documentation in place around this restraint.

Some areas of key risks to people had not been identified, and there were insufficient risk assessments and support plans in place. Processes and systems including quality assurance audits had not identified these omissions.

Improvements had been made to the safety of the environment, however, some issues remained. Most unused rooms were now securely locked so they were inaccessible to people using the service. Chemicals which could be hazardous to people's health were stored securely. There were some new fixtures and fittings in place. However, we observed a ladder obstructing a fire exit which posed a risk of harm if there were an emergency.

Processes were in place to support a safe environment, however, these had not been fully effective. Audits were in place including daily walk arounds, but the most recent daily walk arounds had not identified the ladder obstructing the fire exit.

Family members told us there were enough staff to support their relatives and people raised no concerns about staffing levels. One relative told us, "[The service] seems overstaffed at the moment."

Leaders told us they were overstaffed and staff confirmed there were sufficient staff to support people. Staff told us they were content with the level of training they had received.

There were enough staff to support people. Staff had received a good range of relevant training and training compliance was good. However, the training was not always effective. For example, staff had received training in care planning, yet we found there were issues with the content and quality of the care plans. Staff had received training in communication, yet staff had not identified that more could be done to support effective communication.

No staff had been recruited since the previous inspection. A recruitment policy was in place. Where gaps were identified in previously recruited staff files, risk assessments were now in place.

Staff told us the service was kept clean and they had sufficient time to maintain a good level of cleanliness within the service. Staff were able to support people to help with infection prevention and control, where appropriate.

The service was largely clean and tidy. One relative told us, "It is always lovely and clean, I have no complaints there."

Cleaning schedules were in place alongside an appropriate infection prevention and control policy.

Medicines audits were completed each month by the manager to help identify any shortfalls and make improvements. The manager and staff told us training and competency checks for medicines were carried out regularly to make sure they supported people safely. We saw training records to confirm this. The manager and staff told us about people’s individual medicines needs and we saw person centred care plans and information to help make sure they were supported. The manager told us about how people were supported with their medicines when they were out of the home and a process was in place to safely manage this.

Systems were in place to make sure people’s medicines were administered and recorded safely. Medicines that needed to be given at specific times were given correctly. People’s medicines allergies were recorded accurately. Medicines were stored safely and were administered to people in private in their own rooms. Stocks of medicines were managed efficiently and systems for ordering medicines were effective. A process was in place to support people with non-prescribed (homely remedies) medicines.