CQC report explained · a nursing home
What the CQC found at Averill House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, August 2023
Averill House was rated Requires Improvement; inspectors found medicines were not always managed safely, although action was taken afterwards.
This was an unannounced focused inspection on 12 and 13 June 2023. Inspectors looked at Safe and Well-led because of concerns about medicines and people's nursing care needs. They spoke with people, relatives, staff and visiting professionals, and checked care, medicines and management records.
The main problem was medicines management. Some time-critical medicines were given late, and a high-risk medicine was not given on two occasions. Records about thickener added to drinks were also inaccurate. The report says action was taken after the inspection, but the home's medicines audits had not found these problems.
People told inspectors they felt safe and that staff were kind. There were enough staff, recruitment checks were completed, the home was clean and infection control was well managed. However, leadership and quality checks were rated Requires Improvement, partly because the manager was new and there was no registered manager in post at the time.
Enough staff
Inspectors found staffing levels were enough to meet people's needs. Recruitment checks and induction arrangements were also in place.
“There were enough staff on duty to meet people's needs. This was confirmed by people, relatives, and the staff we spoke with.” from the report
Clean and good infection control
The home was clean, staff used protective equipment safely and the infection control policy was up to date.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed and the provider's infection prevention and control policy was up to date.” from the report
Kind staff and family communication
People described staff as kind and caring. Relatives said communication was good and that they were involved in care plan reviews.
“Relatives said the communication with the home was good, and they were involved in agreeing and reviewing their relatives' care plans.” from the report
Risk assessments
Risk assessments identified people's risks and the steps staff needed to take. Staff were able to explain how they managed risks such as choking and skin problems.
“Risk assessments were in place, and they identified the risks people presented and what action staff needed to take to reduce risk.” from the report
Medicines were not always safe
seriousSome time-critical medicines were not given at the right time, and a high-risk medicine was missed twice for one person. Records about thickener added to drinks were also inaccurate.
“People did not receive their time critical medicines at the right time and could experience symptoms of their condition as a result.” from the report
Checks did not find medicine problems
needs fixingThe home had medicine audits, but they had not identified the issues inspectors found. The report also says systems to prevent the errors happening again were not always evident.
“However, the medicines audits had not identified the issues we found. Staff didn't fully utilise the electronic medicine administration system and were unaware of some administration issues.” from the report
No registered manager in post
needs fixingThere was no registered manager at the inspection. A new temporary manager had been in post for one month and was applying to register while a permanent manager was being recruited.
“At the time of our inspection there was not a registered manager in post. A new 'turnaround' manager had been in post for one month and had submitted an application to register.” from the report
- 01What changes have been made to ensure time-critical and high-risk medicines are given correctly and on time?
- 02How are medicine records, including thickener added to drinks, checked for accuracy now?
- 03What annual medicines refresher training and competency checks have staff completed since the inspection?
- 04Has a permanent manager been appointed and has the manager's CQC registration application been assessed?
- 05What evidence can you show that your medicines audits now identify and prevent repeat errors?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 1 August 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, December 2018
Rated Good; inspectors found safe, kind and person-centred care, with improvements since the previous inspection.
Inspectors visited without warning on 13 and 14 November 2018. They spoke with people living at the home, relatives and staff. They observed care and checked records, medicines, staffing, training, safety checks and how the home was managed.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe and cared for. Inspectors found suitable risk assessments, safe medicines systems, trained staff, respectful care, personalised care plans and varied activities.
At the previous inspection in September 2017, the home had breached Regulation 12 because risks linked to people's behaviour had not been properly assessed. At this inspection, inspectors found that this had improved and the breach was no longer outstanding.
Risk management
The home had detailed risk assessments and strategies to reduce risks to people and others. Staff also reviewed accidents and incidents to help prevent them happening again.
“Risk assessments highlighted the risks people presented and gave detailed strategies to reduce the level of risk to the person and others.” from the report
Staff training
Staff received training, supervision and an induction before working independently. Inspectors found training records showed 97% compliance across the courses checked.
“Staff received the training and supervision required to enable them to carry out their job role effectively.” from the report
Respectful care
Inspectors saw kind and dignified interactions. Staff supported people to make choices, maintain privacy and do as much as possible for themselves.
“Interactions between staff and people living at the home were kind and dignified and we observed friendly joking with people throughout the visit.” from the report
Personalised support
Care plans recorded people's preferences, abilities, health needs, life stories and future wishes. People and their representatives were involved in care planning and reviews.
“Care plans were fully completed and regularly reviewed with people's needs, choices and wishes captured throughout.” from the report
Visible management
The manager was visible around the home and people, relatives and staff said they felt supported. The home used audits, meetings and feedback to identify and complete improvements.
“The registered manager was visible across the service and had oversight and governance systems in place to monitor and improve the home.” from the report
Call bells
minorCall bells could not be heard directly. Staff carried pagers that vibrated, and people told inspectors staff responded promptly, but families should check how this system works for their relative.
“Calls bells were not audible, and staff had a pager in their pocket.” from the report
- 01How will staff make sure my relative can get help quickly if they cannot hear or use the call bell?
- 02How will you assess and review risks if my relative's behaviour or needs change?
- 03How often will you review my relative's care plan, and how can our family take part?
- 04What activities and community groups would be suitable for my relative's interests, culture or communication needs?
- 05How will you respond if we raise a complaint or concern?
This was an unannounced inspection of the overall quality of the home, covering all five CQC areas and both the premises and the care provided. This explanation was written from the published report of 21 December 2018 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 Averill House
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 31 October 2011.
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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At least 100 live-in carers within about an hour of Manchester
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 89 can care for a couple. 10 years' experience on average.
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“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
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