St Andrew's Healthcare - 17 The Avenue

Date of inspection 4 March 2025. The inspection was the provider’s first rated inspection and was prompted by a review of information we held about the provider. St Andrew’s Healthcare 17 The Avenue is a care home with nursing, providing personal care and accommodation. The service supports 1 person with mental health and learning disability needs who is deaf. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. 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 the person using the service 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 was not followed. 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 safeguarding roles and responsibilities. The person’s communication needs were met with the support of interpreters and staff who had been trained to communicate using British Sign Language. Overall, the person was supported by permanent staff who knew them well. Bank staff were also used to cover staff absenteeism, we were informed by staff that bank staff had not always completed British Sign Language training and were not always familiar with the person’s care and support needs. The management team were recruiting additional permanent care staff. The person was supported to lead an active and fulfilling life and their routines, preferences, interests and hobbies, including social and community opportunities were met. The person was involved in discussions and decisions about their care and support. Staff were observed to provide, kind, caring and compassionate support. We observed positive, meaningful and respectful engagement. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. We have asked the provider for an action plan in response to some of the concerns found at this inspection.