CQC report explained · a nursing home
What the CQC found at Avon Cliff
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks, medicines, staffing, recruitment, fire safety and infection control were managed appropriately.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- People, families and staff spoke positively about the management and culture. Quality checks were effective and feedback was used to make improvements.
What inspectors found, May 2023
Avon Cliff was rated Good; inspectors found people were safe and the home was well managed.
This was an unannounced inspection on 20 April 2023. Two inspectors spoke with 8 people, 1 relative and 16 staff. They also checked care and medicines records, staff recruitment files and management records.
The inspectors found people felt safe and knew staff well. Risks were assessed and reviewed, medicines were managed safely, infection control measures were suitable and there were enough staff with the right skills.
The home was described as friendly, open and well led. Managers used checks, feedback and incident reviews to improve care. The overall rating remained Good, the same as at the previous inspection published on 5 December 2018.
People felt safe
People told inspectors they felt safe and had confidence in the staff. Staff understood how to recognise and report abuse.
“People told us they felt safe and had confidence in the staff.” from the report
Good risk management
Risks were assessed, monitored and reviewed. Staff knew people well and understood how to reduce risks while respecting people's freedoms.
“People had their risks assessed, monitored and reviewed.” from the report
Safe staffing and medicines
Inspectors found enough staff with suitable skills and experience. Medicines were given by trained staff and as-needed medicines had clear instructions.
“People were supported by enough staff with the right skills and experience to meet their care and support needs.” from the report
Effective quality checks
The home used several checks and reviews to identify risks and improve care. Incident reviews helped the service learn and reduce weight loss linked to nutrition.
“Quality assurance systems and processes were multi-layered, aligned with regulatory requirements and effective at improving quality of care.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you check that there are enough staff with the right skills on each floor?
- 02How are risks such as falls, eating and drinking, skin problems and health conditions reviewed for my relative?
- 03How do you make sure as-needed medicines are given consistently and appropriately?
- 04How do you prevent and manage infection outbreaks, and how will you keep families informed?
- 05How can my relative and our family give feedback, and how will we know what action has been taken?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key-question ratings were carried forward from the previous inspection published in 2018. This explanation was written from the published report of 25 May 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 kind, safe and personalised care, with some records and staff supervision needing improvement.
This was a routine comprehensive inspection on 31 October and 1 November 2018. The first day was unannounced. Inspectors spoke with people living at the home, staff and visitors. They reviewed care plans, risk assessments, medicines records, audits, maintenance records and staff files.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and visitors gave positive feedback. Inspectors found that staff were caring, trained and understood people's needs. The home was clean, well maintained and had activities based on people's interests.
There had been changes in management, including the recent resignation of the registered manager. Interim management arrangements were in place, and people and staff said they felt supported. Inspectors found some care plans, records and staff supervision were not always completed to the provider's expected standard, but the provider had identified these issues and was taking action.
Kind and respectful staff
Staff knew people well and focused on what reassured and pleased them. Inspectors saw a calm, friendly atmosphere, with staff taking time to talk with people.
“People were observed to look relaxed and comfortable around staff.” from the report
Safe care
Staff understood people's risks and safeguarding responsibilities. Medicines, infection control, accidents and near misses were monitored.
“People were supported by staff who understood the risks they faced and were motivated to support them to live full lives.” from the report
Personalised support
People were involved in planning their care and received support, equipment and activities suited to their needs, preferences and interests.
“They described care that was personalised to their own individual needs” from the report
Good meals and environment
Inspectors found the home clean and well maintained. Mealtimes were relaxed and sociable, and people spoke positively about the food.
“We observed the lunchtime meals and saw it was a sociable and relaxed occasion.” from the report
Open complaints process
People and relatives knew how to raise concerns and felt able to do so. Formal complaints had been dealt with promptly and learning was shared.
“People's concerns and complaints were listened and responded to and used to improve the quality of care.” from the report
Staff supervision
needs fixingSome staff had not received supervision and support as frequently as the provider's policy required. The provider said this was linked to management changes and had a plan to address it.
“Records showed that some people had not received supervision and support as frequently as the registered provider's policy required.” from the report
Care plan detail
needs fixingSome care plans were less detailed and less personal than the information staff could describe. The management team had identified this and was working to improve it.
“Some care plans did not reflect the level of detail that staff told us about.” from the report
Record keeping and analysis
needs fixingRecording was variable. Incorrect weight records showed that checks had not always identified or questioned important information promptly.
“The quality of recording was variable in some areas.” from the report
Waiting during busy periods
minorA visitor said there could be a wait for help getting residents up when several people needed support at once. Management accepted this and said staff should explain delays and prioritise by need.
“If I could change anything, it would be the waiting time for staff to help residents get up.” from the report
- 01Who is currently responsible for managing the home following the registered manager's resignation?
- 02How are you checking that care plans contain enough personal detail and reflect people's current needs?
- 03How often will staff receive supervision, and how will you make sure this meets your own policy?
- 04What checks are now in place to prevent incorrect weights and other recording errors from being missed?
- 05How do staff manage waiting times when several people need help at the same time?
This was a routine comprehensive inspection covering all five CQC questions, and the first day was unannounced. This explanation was written from the published report of 5 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 Avon Cliff
4 rated inspections over 7 years: the service has held its Good rating throughout.
- May 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2018Goodstayed GoodSafe: GoodWell-led: Good
- August 2017Goodstayed GoodSafe: Good
- May 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 23 November 2010.
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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