21 July 2023
During a routine inspection
Avebury House is a residential care home providing personal and nursing care to up to 41 people. At the time of inspection there were 22 people living at the service, set across two floors. Each floor has a lounge and dining area, and there is a large garden. The service includes support for people with dementia, mental health, and physical disabilities.
People’s experience of using this service and what we found
People told us they felt safe, however, risks to people were not always clear and risk management plans were not always proactive in managing risks. We were not assured people were adequately protected from the risk of choking and fire at the time we inspected, however measures have now been put in place to mitigate these risks. There were enough staff to support the current number of people living at the service. Staff understood their roles and responsibilities in safeguarding people from the risk of abuse. People’s medicines were managed safely.
People were supported by staff who were kind and caring. People’s care and support plans were detailed but sometimes contained incorrect information, although these were under review at the time of inspection. People and their relatives were happy with the care provided by staff.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People had mental capacity assessments in place and the provider was making improvements to their assessment of people's capacity to ensure appropriate assessments were completed. Any conditions relating to Deprivation of Liberty Safeguards (DoLS) were being met.
People told us they had enough to eat and drink, but we received mixed feedback about the food provided. Staff received training including an induction when they started work, however this did not always meet individual needs such as training for specific health conditions. The provider had identified this and had plans to improve this.
The provider has recently recruited a Quality Assurance Manager, who completed a mock inspection in the home and produced a comprehensive service improvement plan. A consultancy service had been employed by the provider to support improvements. There had been many improvements since the last rated inspection, in terms of medicine management, pressure care management, and malnutrition. The provider demonstrated an open and transparent culture and was receptive to feedback. We saw changes had been made in response to feedback. Staff felt supported by the current management structure.
The service did not have a registered manager at the time of inspection but was recruiting someone for this position; there was an interim manager in post whilst recruitment took place. The service was being supported by the Regional Manager who at the time of the inspection was the Nominated Individual.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for the service was inadequate (published 2 March 2023) where breaches were found in relation to Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance). The targeted inspection (published 18 April 2023) found the service was no longer in breach of the regulations.
At this inspection, we found a breach in relation to Regulation 12 (Safe Care and Treatment).
This service has been in Special Measures since 2 March 2023. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.