The Avenues Care Centre

Some risks to people had not been identified and care had not been consistently planned to keep people as safe as possible. No care had been planned for 2 people. Medicines were not always managed safely and there was a risk people's medicines would not be effective.

Staff had not been recruited safely and the leadership team could not be assured staff were of good character and had the skills and experience to meet people's needs. Staff had not been supported to develop all the skills they needed to meet people's needs. There were not always enough staff on duty and this had caused a delay in people receiving their medicines at times.

Leadership at the service was not consistently effective and people's safety had reduced since our last inspection. The registered manager and provider did not have oversight of all areas of the service. Effective checks had not been completed to ensure shortfalls were identified and action was taken to address them. This left people at risk of harm. Action had not been taken to understand everyone's experiences of the service and act on the feedback received. The management team had not created an open culture where all staff were confident to share information about accidents, so effective investigations could take place. People were not always referred to in respectful ways.

Following our inspection the provider put an action plan in place to address the shortfalls we found. This included the action to be taken, by when and by who.

Action had been taken to keep people safe following accidents and any safeguarding risks had been acted on. People were supported to remain independent. 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. The service was clean and people were able to receive visitors when they wished.