CQC report explained · a nursing home
What the CQC found at Avon Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were identified, staff were recruited safely and infection control arrangements were in place. They noted two risk plans needing more detail and one person's time-sensitive medicine was not always given at the right time.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found visible and supportive management, good teamwork and quality monitoring systems. The rating improved from Requires improvement at the previous inspection.
What inspectors found, August 2022
Rated Good; inspectors found safe, kind care, but noted staffing pressures, one medicines timing error and some care records needing more detail.
This was an unannounced focused inspection on 26, 27 and 29 July 2022. Inspectors visited in the evening because concerns had been raised about staff approach and personal care. They spoke with people, relatives, staff and healthcare professionals, and reviewed care records, medicines records, recruitment files and quality checks.
The home was rated Good for Safe and Well-led. People said they felt safe and staff were caring and kind. Inspectors found safe recruitment, suitable infection control, medicines systems and checks on risks. They found no evidence to support the concerns about staff interactions at night.
There were some shortfalls. Two risk plans needed more detail, one person did not always receive a time-sensitive medicine at the right time, and staffing shortages meant agency staff were used. Communication with some healthcare professionals also needed improvement. The overall rating remained Good, partly because the other three questions were not inspected and their previous ratings were carried forward.
Kind and respectful staff
People and relatives described staff as caring, kind and person-centred. Inspectors also observed staff interactions during an evening visit and found no evidence to support the concerns raised.
“People told us the staff were caring and kind and worked hard to provide person-centred care.” from the report
Safety systems
The home had systems for identifying risks, managing incidents, checking equipment and safeguarding people. Staff understood how to report concerns.
“Risks to people's safety had been identified and reviewed.” from the report
Medicines records
The electronic medicines system brought medicines records together, and inspectors found no gaps in the records they checked. Staff had training and competence checks.
“People had their medicines as prescribed. The service used an electronic medicines management system which held all medicines related records in one place.” from the report
Quality monitoring
The manager and provider used regular checks and tracked areas such as falls, weight loss, pressure ulcers and medicines incidents. Actions were added to an improvement plan.
“Quality monitoring was in place. The provider had many systems in place to make sure all areas of the service were reviewed so improvements could be identified.” from the report
Visiting
Friends and family were able to visit during the inspection, including in the evening.
“There were no restrictions on visiting at the service.” from the report
Staffing pressures
needs fixingPeople and staff reported occasional shortages linked to sickness. Agency staff were used to fill rota gaps, although inspectors found people's needs were being met during the visit.
“There are not enough carers sometimes, they are run off their feet” from the report
Time-sensitive medicine
seriousOne person did not consistently receive a medicine at the right time. The manager was told and added the issue to the improvement plan.
“We observed one person did not have their time specific medicine consistently at the right time.” from the report
Care plans needed more detail
needs fixingTwo management plans did not include all the guidance shared by healthcare professionals, and some instructions were unclear. Nursing staff updated them during the inspection.
“We did see two management plans that needed more details.” from the report
Communication with professionals
needs fixingSome healthcare professionals said communication with management could be better. The usual staff link for this was not in place because that person was absent, so the provider agreed to review the arrangements.
“Some feedback from professionals about communication was that the service could improve.” from the report
- 01What changes have been made to ensure time-sensitive medicines are always given at the correct time?
- 02How many agency staff are currently being used, and how do you maintain continuity for residents?
- 03Have all care and risk plans been updated with clear guidance from healthcare professionals?
- 04Who is now responsible for day-to-day communication with healthcare professionals when the usual link person is absent?
- 05What evidence can you show that the previous concerns about staff approach, particularly at night, remain resolved?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 26 August 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, February 2021
Avon Court Care Home was rated Good overall, with safe, effective, caring and responsive care, but well-led was Requires Improvement.
Inspectors visited on 16 December 2020. They spoke with people, relatives, staff and health professionals. They reviewed care records, medicines records and records about how the home was managed. They also checked infection control arrangements.
The home had improved since the previous inspection. Medicines, risk management, safeguarding and incident reviews were better. People and relatives said they felt safe, and inspectors found kind and respectful care overall. The home was no longer in breach of the regulations identified at the previous inspection.
The main remaining weakness was leadership and oversight. There was no registered manager at the time, cleaning records were not always completed, and some care and transfer records lacked detail. The home was no longer in Special Measures because it was no longer rated Inadequate overall or in any key question.
Safer medicines
Inspectors found that medicines were being managed safely, with secure storage, suitable records and staff competency checks.
“Medicines were now being managed safely at the home.” from the report
People felt safe
People and relatives reported feeling safe. Staff understood their safeguarding responsibilities and were more confident about reporting concerns.
“People and their relatives told us they felt safe and had no concerns.” from the report
Kind and respectful care
Most observed interactions were dignified and respectful. People and relatives spoke positively about the staff.
“All other interactions observed were dignified and respectful.” from the report
Improving culture
People and staff described positive changes under the current management team, with staff more involved in improvements and clearer about their roles.
“People and staff spoke positively about the service and it was clear that the improvement journey was one involving people and staff in order to sustain the improvements long term.” from the report
Family contact and activities
The home continued to provide activities and ways for people to communicate with relatives during the pandemic.
“Relatives spoke positively about the support to keep in communication with their family members during the pandemic.” from the report
No registered manager
needs fixingThe home did not have a manager registered with the CQC during the inspection. An interim manager and other senior staff were supporting it.
“At the time of this inspection the service did not have a manager registered with the Care Quality Commission.” from the report
Cleaning records
needs fixingHigh-touch cleaning had been introduced, but the records were not always completed. This meant inspectors could not always see evidence that the cleaning had taken place.
“However, we saw the documents used to record this cleaning were not always used.” from the report
Care information varied
needs fixingSome care plans used generic wording or referred to people as 'resident'. Some transfer documents also contained very little information about people's needs.
“Whilst some care plans contained thorough and personalised information, we saw some that had generic guidance and referred to people as 'resident'.” from the report
One undignified interaction
minorInspectors saw one staff interaction that did not promote a person's dignity. Management addressed it during the inspection, and other observed interactions were respectful.
“We saw one example of an undignified interaction that did not promote a person's dignity.” from the report
End of life medicines plan
needs fixingOne person who had anticipatory end of life medicines did not have a separate care plan or specific information about them in the care plan.
“We recommend that the provider reviews their medicines policy to ensure care plans are in place for people who are prescribed anticipatory end of life medicines.” from the report
- 01What is the current position on appointing and registering a manager for the home?
- 02How are the monthly action plans being completed and checked, and what improvements are still outstanding?
- 03How do you make sure high-touch cleaning is completed and recorded every time?
- 04How will you ensure anticipatory end of life medicines have clear, separate care plan information?
- 05How do you check that care plans and hospital transfer documents contain detailed, personalised information?
This was a follow-up inspection of improvements required after the previous inspection, and it also checked infection prevention and control measures; the report provides ratings for all five key questions. This explanation was written from the published report of 5 February 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 Avon Court Care Home
6 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- August 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- November 2020Requires improvementSafe: InadequateResponsive: Requires improvementWell-led: Requires improvement
- March 2020Inspected but not ratedSafe: InadequateEffective: Requires improvementResponsive: Inadequate
- December 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Requires improvement
- October 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2017
Registered with the Care Quality Commission on 31 January 2017.
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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