CQC report explained · a residential care home
What the CQC found at Avon Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff to meet people's needs, suitable recruitment checks, safeguarding procedures and safe medicines systems. Risks such as falls, poor nutrition and skin damage were assessed and monitored.
- Effective?
- Good
- People's choices, consent and best-interest decisions were supported. Inspectors found improvements to mealtimes, with suitable food, drinks and support, although they recommended further changes to make the home easier for people with dementia to navigate.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found clearer management structures, better monitoring and effective audits. Managers, relatives and staff spoke positively about the service and said concerns could be raised.
What inspectors found, July 2023
Rated Good; inspectors found safe, kind care and clear improvements since the previous inspection, with dementia-friendly signage still needing attention.
This was an unannounced focused inspection on 27 April, 3 May and 18 May 2023. Inspectors spoke with people living at the home, relatives, staff and managers. They observed care and checked care, medicines, recruitment, training, incident and quality records.
The home was rated Good overall. Safe, Effective and Well-led were each rated Good. Inspectors found enough staff, safe medicines practice, suitable safeguarding systems, support with food and drink, and better oversight by managers.
The previous rating was Requires Improvement, published on 12 November 2021. The provider had been in breach of regulations at that inspection, but inspectors found the breaches had been addressed. The home had also improved mealtimes after the previous recommendation.
This inspection only assessed Safe, Effective and Well-led. Caring and Responsive were not inspected during this visit, so their previous ratings were carried forward into the overall rating.
Enough staff
Staffing had increased since the previous inspection. Inspectors found enough staff on duty, and people and relatives said help was available without long waits.
“There were enough staff on duty to meet people's individual needs and maintain their safety.” from the report
Safe medicines
Medicines were given as prescribed, records had no gaps and staff had training and competency checks.
“Medicine administration records were complete and no gaps in recording were identified.” from the report
Kind and respectful care
Inspectors found a calm atmosphere and staff who knew people's needs and preferences. People were treated with kindness, respect and compassion.
“People were treated with kindness, respect, and compassion.” from the report
Improved mealtimes
The previous recommendation about mealtimes had been acted on. Inspectors saw a calm meal with choices of food and drinks and support for people who needed it.
“At this inspection we saw that the mealtime experience was positive for people.” from the report
Stronger management checks
The home had clearer responsibilities, more management support and regular audits. Managers acted on issues and shared actions with staff.
“We saw quality assurance and governance systems were in place.” from the report
Limited dementia-friendly signs
minorInspectors found a lack of signage to help people navigate the building. They raised this with managers and recommended further adaptations.
“however there was a lack of signage throughout the home to support people to navigate the building.” from the report
- 01What changes have been made to signage and navigation for people living with dementia since this inspection?
- 02How do you check that staffing levels remain enough for people's individual needs, including appointments and outings?
- 03How are medicines audits and staff competency checks kept up to date?
- 04How are people's food preferences, cultural needs and support at mealtimes recorded and reviewed?
- 05What were the previous ratings for Caring and Responsive, and what has changed in those areas since the last comprehensive inspection?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings carried forward into the overall rating. This explanation was written from the published report of 6 July 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, November 2021
Requires Improvement; inspectors found kind care, but concerns about staffing, risk records, legal safeguards and management oversight.
Inspectors visited unannounced on 28 July and 10 September 2021. They spoke with people, relatives, staff and managers, and checked care plans, risk assessments, medicines records, staff files and management records.
People and relatives generally said the home felt safe and that staff were kind and knew people well. Medicines were given safely, infection control was mostly good, staff received training, and people were supported to access healthcare.
However, staff were not always deployed effectively. Some people did not have suitable care plans or risk assessments, and some DoLS applications were late. Inspectors also found unclear management arrangements and weak checks on the quality and safety of care.
The overall rating changed from Good to Requires Improvement. The home was rated Requires Improvement for Safe, Effective and Well-led. Caring and Responsive were not inspected at this visit, so their previous ratings were carried forward.
Kind and familiar staff
People and relatives described staff as kind, helpful and compassionate. Inspectors also saw people responding positively to staff.
“People and relatives we spoke with said they felt Avon Lodge was a safe place to live and staff knew people well.” from the report
Medicines
Inspectors found that medicines were given as prescribed and records, storage and disposal systems were in place.
“People received their medicines safely and as prescribed.” from the report
Infection control
The home was clean and had procedures for safe visiting during COVID-19. Inspectors observed generally good infection control, although some mask use needed correcting.
“Throughout the inspection, we observed overall good infection control processes.” from the report
Healthcare and activities
People were supported with healthcare referrals, GP appointments and activities based on their interests. Rooms could also be personalised.
“People were encouraged to take part in activities and there was an activities person in place who was aware of people's likes and dislikes.” from the report
Staff deployment
seriousInspectors found that staff were not deployed effectively to meet people's needs. Some staff said they felt there were not enough staff, and the provider was in breach of the staffing regulation.
“The provider failed to ensure staff were appropriately deployed.” from the report
Missing risk information
seriousThree newly admitted people had no care plans or risk assessments at the time of inspection. Two others had emergency plans that did not give enough guidance about known risks.
“We found three people who had been admitted shortly prior the inspection did not have any care plans or risk assessments completed.” from the report
Late legal safeguards
seriousDoLS applications were not always made on time. One person's authorisation had expired for two months before a renewal application was submitted, meaning the person was unlawfully deprived of their liberty.
“This meant the person was being illegally deprived of their liberty for two months.” from the report
Weak management oversight
seriousStaff found the management structure confusing. Care plan reviews and accident analysis did not consistently identify or address problems, and the provider was in breach of the good governance regulation.
“The provider had failed to ensure adequate oversight and good governance of the home.” from the report
Mealtimes
needs fixingInspectors found that lunch could feel rushed and was not always an enjoyable or well-supported experience. They recommended reviewing mealtime systems.
“We recommend the provider review systems and processes around mealtimes to improve people's experience.” from the report
- 01How are staff deployed on each shift, and what has changed since inspectors found deployment was not effective?
- 02How do you now make sure every new resident has a care plan and risk assessment immediately?
- 03How are DoLS authorisations monitored, renewed and reviewed before they expire?
- 04What has changed in the management structure, and who should families and staff contact with concerns?
- 05What improvements have been made to mealtimes, including support for people eating in their rooms?
This was a planned inspection that rated Safe, Effective and Well-led; Caring and Responsive were not inspected, so their previous ratings were carried forward. This explanation was written from the published report of 12 November 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 Lodge
7 rated inspections over 8 years: the service has improved, from Inadequate to Good.
- July 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- September 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- June 2016Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- November 2015InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 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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