23/23a The Avenue

Date of inspection 3 March 2025. The inspection was the provider’s first rated inspection and was prompted by a review of information we held about the provider.23 / 23A is a care home providing personal care and accommodation for up to 5 people. The service supports people with mental health needs who are deaf. The service was supporting 2 people at the time of this inspection who were receiving the regulated activity of personal care.During this inspection, we identified 2 breaches of regulation, safe care and treatment regarding medicines management and governance of the service.The provider’s medicines policy was not being followed. A lack of medicines systems and processes put people at increased risk of harm. The provider’s governance systems and processes that assessed, monitored, reviewed and mitigated risks to make improvements were not fully effective. Best practice guidance in relation to infection prevention and control, and how food stocks were managed were not followed. There was a high use of bank staff, but permanent staff were being recruited. Staff recruitment checks found gaps in employment records, but no action had been taken to follow up the reason for this.Staff were aware of their roles and responsibilities in protecting people from abuse and avoidable harm. People’s communication needs were met with the support of interpreters and staff who had been trained to communicate using British Sign Language.People were supported to lead active and fulfilling lives and their routines, preferences, interests and hobbies, including social and community opportunities were met. People received support to access health services and were involved in discussions and decisions about their care and support.Permanent staff knew people well. Staff overall were observed to provide, kind, caring and compassionate support.