CQC report explained · a nursing home
What the CQC found at Avocet Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found systems to assess and manage risks, safeguard people, manage medicines and control infection. Staffing levels were reviewed and adjusted when people's needs changed.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found effective audits, open management and systems for listening to people and acting on concerns. There was a new manager, but the manager was not yet registered at the time of inspection.
What inspectors found, June 2022
Rated Good; inspectors found safe care and stronger management, although there was no registered manager in post at the visit.
This was an unannounced focused inspection on 13 May 2022. One inspector spoke with people, relatives and staff, observed care, and reviewed care records, audits and other documents.
The home was rated Good for Safe and Well-led. Inspectors found safe medicines systems, suitable staffing arrangements, infection control measures, and systems for learning from accidents and incidents. People and relatives said they felt safe and had enough staff support.
The previous rating was Requires Improvement. The home had previously breached Regulation 17 about governance, but inspectors found enough improvement and said the breach had been resolved. This inspection did not reassess Caring, Effective or Responsive, so their earlier ratings were carried forward.
Safer risk management
Care records set out people's risks and guidance for staff. Equipment and the environment were checked, and staff responded quickly when someone was at risk of falling.
“Records showed there were systems in place to ensure the environment and equipment was checked to ensure they were safe for use and fit for purpose.” from the report
Medicines handled safely
Inspectors found medicines were stored, administered and recorded safely. Staff responsible for medicines had training and competency checks.
“People received their medicines when they were required and there were systems in place for the safe management of medicines, including storage, ordering, administering, recording and disposal.” from the report
Family visits supported
People could receive visits from family and friends. Infection control arrangements included PPE, testing and safe visiting processes.
“People were able to have visits from their family and friends. This was confirmed by people using the service, their relatives and our observations during our inspection visit.” from the report
Improvement since the last inspection
The previous governance breach was resolved. Inspectors also found better arrangements for individual and disposable slings, and regular checks of exposed pipes and radiators.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Manager registration pending
minorThere was no registered manager in post during the inspection. A manager had applied for registration, but the application was still being processed.
“At the time of our inspection there was not a registered manager in post.” from the report
Ongoing recruitment
minorThe home was still recruiting staff and used agency staff to cover vacancies. Inspectors recorded that these agency staff were regular workers who knew people well.
“The service was continuously recruiting staff, this included recruiting staff from overseas.” from the report
- 01Has the manager's application to become a registered manager now been approved?
- 02How many staff vacancies are there now, and how often are agency staff used?
- 03How quickly are call bells currently answered, and how are response times monitored?
- 04What were the results of the next satisfaction surveys and what actions followed them?
This was a focused inspection of Safe and Well-led, including infection control; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 15 June 2022 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, October 2021
Rated Requires Improvement; inspectors found kind care, but risks, medicines records and quality checks were not always managed well.
This was an unannounced focused inspection on 23 and 24 August 2021. Inspectors looked at Safe and Well-led in Harlech House, following concerns about how risks were managed. They spoke with people, relatives, staff and visiting professionals, observed care and checked records.
People and relatives said staff were kind and caring. Inspectors saw respectful care, safe medicines administration, completed recruitment checks and arrangements to support visits. Staff knew how to report abuse and worked with health professionals.
However, some risks were not properly assessed or managed. Shared moving equipment was not cleaned between uses, some call bell cords could cause trips, and recording of topical medicines was incomplete. Quality checks had not found these problems. The overall rating changed from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement.
Kind and respectful staff
People and relatives praised the staff. Inspectors saw staff being attentive, respectful and encouraging people to make choices.
“People and relatives praised staff for being kind and caring. We observed that staff were attentive and interacted with people in a respectful way.” from the report
Safeguarding awareness
Staff understood how to recognise and report abuse. They said they were confident concerns would be dealt with through safeguarding procedures.
“Staff told us that they knew how to raise safeguarding concerns and expressed confidence in the process.” from the report
Staffing arrangements
The manager used dependency information to plan staffing and had arrangements to cover sickness. Admissions in one part of the home had been temporarily paused when dependency increased.
“The manager used a dependency tool to establish the staffing levels to ensure there were enough staff on each shift to meet people's needs.” from the report
Positive partnership working
Visiting professionals said the home contacted them appropriately and followed their advice. Staff sought specialist help when needed.
“Visiting professionals confirmed that the service contacted them appropriately and followed their guidance.” from the report
Shared moving equipment
seriousShared hoist slings were used without being laundered between people. Inspectors said this created a risk of cross infection.
“However, staff used shared hoist slings which were not laundered between each person. This presented a risk of cross infection.” from the report
Risks from hot surfaces and drinks
seriousPipes and radiators were uncovered and were not initially covered by a detailed risk assessment. There had also been a significant burn from a hot drink and two further scalding incidents.
“We also saw that two further scalding incidents had occurred, although there had been no serious injury.” from the report
Topical medicines records
seriousRecords and oversight did not show reliably that topical medicines were given as prescribed. The new recording system needed time to become established.
“We found significant gaps in recording and could not be assured that people were receiving these as prescribed.” from the report
Quality checks missed problems
seriousThe home carried out audits, but they had not identified or fixed several problems with risk management and medicines.
“Quality assurance processes were in place including a significant number of audits, but these were not always effective in identifying and addressing areas for improvement.” from the report
Call bell trip hazards
needs fixingSome call bell leads stretched across the floor and could cause falls. The manager said pendant alarms would be reviewed for people who needed them.
“However, we observed that call bell leads presented a falls risk as they stretched out across the floor.” from the report
- 01How are shared hoist slings now cleaned or laundered between each person?
- 02What detailed risk assessment and checking system is now in place for uncovered pipes and radiators?
- 03How do you now record and audit topical medicines to prove they are given as prescribed?
- 04How are call bell cords and pendant alarms managed for people at risk of falling?
- 05What action has been taken after the hot drink burn and the two further scalding incidents?
This was a focused inspection of Safe and Well-led in Harlech House; the other key questions were not inspected and their previous ratings carried over. This explanation was written from the published report of 2 October 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.
Every inspection of Avocet Court
4 rated inspections over 3 years: the service has held its Good rating throughout.
- June 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2020Goodstayed GoodSafe: GoodWell-led: Good
- November 2019GoodSafe: GoodResponsive: Requires improvementWell-led: Good
- January 2019
Registered with the Care Quality Commission on 24 January 2019.
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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