CQC report explained · a nursing home
What the CQC found at Avebury House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Fire doors were not compliant at the time of the visit, and risk plans did not always give clear guidance about falls or choking. Medicines and staffing were managed safely, and extra fire and choking measures were put in place after inspectors raised concerns.
- Effective?
- Requires improvement
- People did not always receive support suited to their mental health and communication needs. Staff lacked some condition-specific training, and relatives were not always involved in care decisions.
- Caring?
- Good
- People and relatives described staff as kind, friendly and respectful. Inspectors saw people being supported with dignity and involved in day-to-day choices, although one privacy concern about a sign in a bedroom was raised.
- Responsive?
- Requires improvement
- Care plans were detailed in places but sometimes contained incorrect or unclear information. Communication support and opportunities for community activities did not always meet people's needs.
- Well-led?
- Requires improvement
- There had been significant leadership changes and a detailed improvement plan was in place. The home was open to feedback and had made improvements, but it did not have a registered manager and some communication and governance systems were not yet fully effective.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found kind care and improvements, but risks around fire safety, choking and care records were not fully managed.
This was an unannounced follow-up inspection on 21 and 27 July 2023. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care, medicine, staff and management records.
The home had enough staff for the number of people living there. Medicines were managed safely, and people were treated kindly. However, fire doors were unsafe during the visit, guidance about falls was not clear, and inspectors were not assured that choking risks were always managed safely. The provider put extra safety measures in place during and after the inspection.
Some care plans had incorrect or unclear information. Staff did not always have training for people's specific health conditions, including mental health needs. Relatives were not always involved in care decisions, and people's communication and activity needs were not always fully met.
The overall rating and four of the five question ratings were Requires Improvement. Caring was rated Good. The home had previously been rated Inadequate and placed in special measures, but it is no longer rated Inadequate or in special measures. The provider must send an action plan and CQC will continue to monitor progress.
Kind and respectful staff
People and relatives spoke positively about the care. Inspectors saw staff being warm, respectful and responsive to people's choices.
“People and their relatives spoke positively about the care and support provided by staff.” from the report
Medicines managed safely
Inspectors saw nurses giving medicines as prescribed. Monthly audits identified and addressed medicine concerns.
“Medicines were managed safely in line with national best practice guidance.” from the report
Enough staff at the visit
There were enough staff for the number of people living at the home. Call bells were answered promptly, and recruitment had reduced the need for agency staff.
“There were enough staff to support people safely, however the building was half occupied at the time of our inspection.” from the report
Open approach to improvement
The provider had appointed a quality assurance manager, used external support and created a detailed improvement plan. Inspectors saw that feedback led to changes.
“The provider demonstrated an open and transparent culture and was receptive to feedback.” from the report
Fire safety
seriousSeveral fire doors needed repair or replacement. At the time of the visit, the provider had not done enough to reduce the risk while waiting for the work.
“The provider had not mitigated the fire risks to people whilst the fire doors remained unsafe at the time of our site visit.” from the report
Choking and other risks
seriousRisk plans did not always explain clearly how staff should reduce risks. Inspectors saw a person receiving food that did not match their recorded needs, without a capacity assessment to show the risks were understood.
“We were not assured people were adequately protected from the risk of choking and fire at the time we inspected” from the report
Care records were unclear
needs fixingSome care plans contained incorrect or conflicting information, including different recorded food and fluid textures. The provider was reviewing these records.
“People's care plans were detailed in some areas, however some contained incorrect or unclear information.” from the report
Staff training
needs fixingStaff did not always have training for people's specific health conditions. The provider had identified this and planned to improve it.
“There was a lack of training specific to individual needs.” from the report
Communication and activities
needs fixingPeople's communication needs were not always met, and alternative communication methods had not been explored effectively. One person said there had been no day trips outside hospital visits.
“Alternative methods of communication had not been effectively explored for this person.” from the report
- 01What has been done to repair or replace the fire doors, and what temporary fire safety measures remain in place?
- 02How are choking risks and required food textures now recorded, checked and communicated to every member of staff?
- 03What condition-specific training have staff completed, particularly for mental health conditions?
- 04How will you involve my relative and our family in care decisions and care plan reviews?
- 05What changes have been made to support communication needs and provide activities outside the home?
This was an unannounced follow-up inspection covering all five key questions, with infection prevention and control also checked; it followed an earlier Inadequate inspection and a targeted inspection. This explanation was written from the published report of 7 September 2023 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, April 2023
Rated Inadequate and remains in special measures; inspectors found improvements in safety and management, but the full rating was not reassessed.
This was an unannounced targeted inspection on 23 March 2023. Inspectors checked whether the home had acted on warning notices about safe care and treatment, and good governance. They spoke with people, relatives, staff and health and social care professionals, and reviewed care, risk, medicines and audit records.
Inspectors found that risk assessments were in place and staff followed them. Medicines were recorded and managed safely. The home was clean, and infection control systems had improved. The provider had also introduced action plans, audits and a management team to address earlier problems.
The inspection did not reassess the whole Safe or Well-led questions, or any of the other three questions. These ratings were therefore not changed. The overall rating remains Inadequate, and the home remains in special measures.
Risk management
Risk assessments covered issues such as falls, pressure ulcers and health conditions. Staff understood the plans and were seen following them.
“Staff demonstrated a good understanding of the risk management plans and the actions they needed to take to keep people safe.” from the report
Medicines
Medicine records were complete and included clear instructions for medicines taken when needed. People said they received medicines on time.
“People were supported to safely take the medicines they were prescribed.” from the report
Cleanliness and infection control
The home was clean and fresh. Extra cleaning tasks and infection control systems had been introduced since the previous inspection.
“The home was clean and smelt fresh in all areas.” from the report
Improvement planning
The provider had detailed action plans with named responsibilities and regular reviews. Audits were identifying shortfalls and tracking actions.
“The provider had developed detailed action plans to address the shortfalls identified at the last inspection.” from the report
Overall rating remains Inadequate
seriousThe home is still rated Inadequate because this targeted inspection did not reassess the full service. It remains in special measures.
“The overall rating for the service has not changed following this targeted inspection and remains inadequate.” from the report
No registered manager
needs fixingThere was no registered manager in post when inspectors visited. The report says the service is required to have one.
“At the time of our inspection there was not a registered manager in post.” from the report
Improvements still need to be embedded
needs fixingThe management team had plans to make the improvements lasting, including addressing gaps in staff skills and knowledge through training and supervision.
“There were plans for how the service could move forwards and ensure the immediate improvements were embedded in practice.” from the report
- 01What evidence can you show that the improvements in risk assessments and repositioning records are now being maintained?
- 02How are you checking that medicines taken when needed are given according to each person's protocol?
- 03Who is responsible for managing the home while there is no registered manager in post?
- 04What training and supervision are staff receiving to address the gaps in skills and knowledge?
- 05When will the next comprehensive inspection take place, and what improvements must be shown for the Inadequate rating to change?
This was a targeted inspection of specific parts of Safe and Well-led, focused on Regulations 12 and 17; it did not assess the full five questions, so the previous overall Inadequate rating remained. This explanation was written from the published report of 18 April 2023 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 Avebury House
4 rated inspections over 2 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2023Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- March 2023Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- May 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2021GoodSafe: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- July 2020
Registered with the Care Quality Commission on 6 July 2020.
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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