CQC report explained · a residential care home
What the CQC found at Avon Valley Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Infection control, staffing, risk assessments, recruitment, medicines and incident reporting were judged safe.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Well-led?
- Good
- Inspectors found improved quality checks, regular audits and good management oversight. Staff described a supportive team culture and managers who were open to learning and improvement.
What inspectors found, July 2022
Rated Good; inspectors found major improvements in infection control and management oversight after the previous Requires Improvement rating.
This was an unannounced focused inspection on 15 June 2022. One inspector spoke with the manager, deputy, quality manager, staff and people living at the home. They observed care and checked records about staffing, recruitment, infection control and quality checks.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found people felt safe, there were enough staff, medicines were managed safely, risks were assessed and safeguarding procedures were understood.
There had been significant improvements since the previous inspection in September 2021. Staff were wearing masks correctly, had received further training and were checked through spot checks and audits. Management systems had also improved.
This inspection only looked at Safe and Well-led. The overall rating also used the previous ratings for the other areas, which were not inspected during this visit.
Improved infection control
Staff were wearing masks correctly and had been retrained. The home used spot checks and audits to monitor infection control practice.
“We observed all staff were wearing a face mask safely in accordance with the guidance from the DHSC (Department Health Social Care).” from the report
Enough staff
Inspectors found there were sufficient staff to meet people's needs. Recruitment included the required pre-employment checks.
“There were sufficient numbers of staff to support people and to meet their needs.” from the report
Safe medicines management
Medicines were given by trained staff, checked through audits and recorded on an electronic system.
“Medicines were audited regularly to check people had received their medicines safely.” from the report
Stronger oversight
Managers carried out audits covering care plans, medicines, infection control, accidents and other risks. A regional manager also visited and checked the home.
“Since the last inspection improvements had been made to quality assurance monitoring systems.” from the report
Supportive staff culture
Staff said they felt supported and could speak to managers. Inspectors found the team worked together to provide person-centred care.
“I think we have a really supportive team here. We all help each other, and I know I can speak to the management at any time” from the report
Inspectors raised no specific concerns in this report.
- 01How are you continuing the mask checks, infection control training and spot audits now?
- 02What do your latest audits show about infection control, medicines, care plans and incidents?
- 03How do you make sure there are enough suitably trained staff when people are absent or on leave?
- 04What were the ratings and findings for Effective, Caring and Responsive at the previous comprehensive inspection?
- 05How are relatives involved in giving feedback and hearing about changes to the home?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 19 July 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 and personalised care, but infection control and quality checks were not reliable enough.
This was the first planned inspection since the home registered. Inspectors visited on 15 September 2021, spoke with people, relatives and staff, observed care, and checked care, medicines, training and other records.
The home was rated Good for Effective, Caring and Responsive care. Inspectors found that staff knew people well, respected their dignity, supported choice, provided activities and worked with health professionals.
The home was rated Requires Improvement for Safe and Well-led. Three staff members were seen wearing masks under their chins, and staff did not always follow infection control guidance. Quality checks had identified some PPE concerns but had not stopped them happening again.
Inspectors found breaches of Regulations 12 and 17. The provider was asked for an action plan, and CQC said it would monitor progress and return under its re-inspection programme.
Kind and respectful staff
Inspectors saw staff responding calmly to distress and treating people with dignity. Relatives also spoke positively about the care.
“People were supported by staff who treated them with dignity and respect.” from the report
Personalised care
Care plans included people's histories, preferences, health needs and communication needs. Staff knew people well.
“People's care plans were personalised and tailored to their individual needs.” from the report
Choice and independence
People were supported to choose their clothes, meals, routines and where to eat. Their wishes about independence were recorded.
“People were encouraged to make choices about their day to day routines and activities.” from the report
Activities and relationships
The home offered group and one-to-one activities and helped people maintain important relationships with relatives.
“People were engaged in activities to occupy them.” from the report
Medicines and risk management
Medicines were stored securely and monitored electronically. Risk assessments gave staff guidance on reducing risks to people.
“The home used an electronic medicine monitoring system.” from the report
Masks were not worn safely
seriousInspectors saw three staff members wearing masks under their chins. Staff were not consistently following infection control guidance, creating a risk of infection.
“These shortfalls meant people were not always protected from the risk of infection because official guidance was not being followed.” from the report
Quality checks did not prevent repeated problems
seriousManagers had identified staff misusing PPE, but their checks had not ensured that the problem stopped. This meant governance systems were not robust enough.
“This meant systems for monitoring the service and ensuring people and staff were kept safe were not always robust” from the report
Mixed views about staffing
needs fixingPeople and staff generally said there were enough staff, but some relatives felt staff were rushed or that staffing was short, particularly during COVID-19.
“They don't spend a lot of time chatting to me, they are always in a rush; they are definitely short staffed” from the report
Mixed views about food
minorInspectors saw appetising food and menu choices, but some relatives said meals did not always suit their family member or were tasteless.
“The food is not always to my relatives liking, they prefer plain food” from the report
- 01What has changed since the inspection to make sure all staff wear face masks correctly and follow infection control guidance?
- 02How do managers now check PPE practice, and what happens if staff do not follow the required procedure?
- 03What action has been taken in response to the Regulation 12 and Regulation 17 breaches?
- 04How do you make sure staffing levels remain enough as the number of people living at the home changes?
- 05How are meals adapted for people who prefer plain food or have different dietary tastes?
This was the first planned inspection of the newly registered home and covered all five key questions, with infection prevention and control specifically assessed under Safe. This explanation was written from the published report of 22 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 Avon Valley Care Home
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- July 2019
Registered with the Care Quality Commission on 11 July 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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