CQC report explained · a nursing home
What the CQC found at Avalon Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found suitable staffing, safe medicines management, daily air mattress checks and appropriate infection control measures.
- Effective?
- Good
- People received effective care and good outcomes. The home had improved consent and mental capacity processes, supported eating and drinking, and provided relevant staff training.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- The home had a clear management structure and more effective quality checks. Staff, relatives and professionals spoke positively about the management team and teamwork.
What inspectors found, September 2021
Avalon Nursing Home was rated Good; inspectors found safe, effective and well-managed care, with improvements since the previous inspection.
This was an unannounced, focused inspection on 6 September 2021. Inspectors spoke with people, relatives, staff and professionals. They observed care and reviewed care, medicines, staffing and management records.
The home was rated Good overall. Safe, Effective and Well-led were each rated Good. Inspectors found people were protected from abuse and avoidable harm, medicines were managed safely, staffing levels met people's needs, and infection control arrangements were suitable.
People's care needs were assessed and staff supported people to make choices. The home had improved how it handled consent and mental capacity decisions. Staff were described as supportive, skilled and person-centred, and management systems were being used more effectively.
The previous rating was Requires Improvement, published in July 2019, when the home breached Regulation 11 about consent. Inspectors found enough improvement had been made and the home was no longer in breach. Caring and Responsive were not examined during this focused inspection, so their previous ratings carried over.
Safety improvements
The home had improved its management of pressure ulcer risks and other risks to residents. Air mattress checks were completed daily and risk assessments contained detailed guidance for staff.
“At this inspection, we found improvements had been made; air mattress checks were completed daily, and the results were recorded on a document reviewed by senior staff.” from the report
Safe medicines
Medicines were stored and managed safely. Trolleys were supervised when in use, and staff had person-centred guidance for medicines given when needed.
“Medicines trolleys were supervised while in use and secured to the wall in the medicines room, when not in use.” from the report
Respecting choices
The home had improved its mental capacity assessments and considered less restrictive options. Staff supported people to make their own decisions where possible.
“At this inspection, we found improvements had been made, and detailed, person-centred capacity assessments about specific decisions, were in place.” from the report
Supportive staff
Staff received training, supervision and support relevant to their roles. Inspectors found enough suitably qualified staff to meet people's needs.
“There were sufficient numbers of suitably qualified staff to meet people's needs and staff were recruited safely.” from the report
Stronger oversight
The home had introduced regular audits and action plans to identify and address concerns, errors and omissions.
“A comprehensive programme of quality checks and audits was used to monitor care provision.” from the report
Inspectors raised no specific concerns in this report.
- 01How are daily air mattress checks and pressure ulcer risks recorded and reviewed now?
- 02How do you check that consent and mental capacity decisions are specific to each person and decision?
- 03How do you make sure staffing levels remain sufficient when residents' needs change?
- 04What recent concerns have your quality audits identified, and what action was taken?
- 05How do you currently support visits and prevent the spread of infection?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not assessed and their previous ratings were carried over. This explanation was written from the published report of 18 September 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2019
Avalon Nursing Home was rated Requires Improvement; inspectors found kind, responsive care but gaps in safety, consent records and management checks.
Inspectors visited without warning on 21 May 2019. They reviewed care and medicine records, staff files, audits and policies. They spoke with people living in the home, relatives, staff and health and social care professionals. They also observed care for people who could not describe their experiences.
The home was caring and responsive. People were treated with kindness and respect, and staff knew them well. People had access to activities, healthcare and support with eating and drinking. The environment was clean, bright and well maintained.
However, some risks were not managed well enough. Air flow mattresses were not always checked, some care plans lacked important detail, and records did not always show that legal guidance had been followed when people could not make decisions for themselves. Management audits had also lapsed shortly before the inspection.
The overall rating changed from Good at the previous inspection to Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were rated Good.
Kind and respectful care
People were supported with kindness, dignity and respect. Staff knew people well and helped them stay as independent as possible.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Activities and personal choice
People could take part in a broad range of activities and choose whether to join in. Their interests, communication needs and personal histories were considered.
“People were able to participate in a wide range of activities.” from the report
Access to healthcare
People received routine and specialist healthcare when needed. Staff worked with health professionals and had established regular GP visits to the home.
“People were supported to access routine and specialist healthcare services when necessary.” from the report
Clean and suitable environment
The home was bright, clean and well maintained. It included sensory objects and areas designed to interest and reassure people living with dementia.
“The environment was bright and well maintained and met people's needs and preferences.” from the report
Pressure ulcer prevention checks
seriousSome specialist air flow mattresses were not checked as required, and their settings were not always clearly recorded. Inspectors said this created a potential risk of harm.
“People were placed at potential risk of harm from pressure ulcers.” from the report
Incomplete risk guidance
seriousCare plans for people who could display behaviours which challenge did not always explain how staff should manage risks. This could leave staff without enough written guidance.
“Care plans for people who could display behaviours which challenge lacked detail.” from the report
Consent and best-interest records
seriousRecords did not always show that capacity, consent and less restrictive options had been properly considered for safety measures such as door alarms and sensor mats.
“The service did not always seek consent to care and treatment in line with legislation and guidance.” from the report
Care plans not always current
needs fixingSome care plans contained old or conflicting information, including changes to falls monitoring and medicine support. This could lead to incorrect care being given.
“Examples such as these could lead to confusion amongst staff, or incorrect support or care being given.” from the report
Management checks had lapsed
needs fixingAudits and checks had not been completed regularly in the weeks before the inspection. They had also failed to identify some of the shortfalls found by inspectors.
“These checks had not always identified the shortfalls we identified during our inspection.” from the report
Medicine trolley security
seriousMedicine trolleys were not always securely anchored or supervised when left in corridor areas. Inspectors also found that one person's self-administered medicines were not monitored in line with best practice.
“There was a risk because medicines trolleys were not anchored securely or supervised by staff when they were in corridor areas.” from the report
- 01What checks are now completed on specialist air flow mattresses, and how are the correct settings recorded?
- 02How do you record capacity assessments, consent and best-interest decisions for door alarms, sensor mats and other restrictions?
- 03How have care plans been checked and updated so that old or conflicting instructions are removed?
- 04How often are medicines, care plans and health and safety audits now completed, and who checks that actions are finished?
- 05How are medicine trolleys kept secure and supervised when they are in corridor areas?
This was an unannounced planned inspection covering all five CQC questions, with the home and the care provided both assessed. This explanation was written from the published report of 5 July 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Avalon Nursing Home
4 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- September 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2015
Registered with the Care Quality Commission on 4 August 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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