CQC report explained · a residential care home
What the CQC found at Avondale Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors were assured that the home was preventing and managing infection risks. They checked visitors, social distancing, admissions, protective equipment, testing, cleaning and infection control policies.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, April 2021
Inspected but not rated; inspectors were assured that the home had effective infection prevention and control measures.
This was an announced, targeted inspection on 22 March 2021. It looked at how the home was preventing and controlling COVID-19 infections.
Inspectors found good arrangements for visitors, social distancing, cleaning, personal protective equipment and testing. Staff were observed wearing protective equipment correctly, and regular checks were carried out.
The home supported people to keep in touch with loved ones and supported their wellbeing. Inspectors were assured about the infection control measures, but this inspection did not give an overall quality rating.
Safe visiting
The home had procedures to let visitors enter safely and had a designated visiting area. Staff also helped people stay in contact with loved ones.
“Good procedures were in place to allow visitors to safely enter the service.” from the report
Protective equipment
There was enough personal protective equipment, staff wore it correctly and checks were made to ensure this continued.
“There was enough PPE at the service. Staff were observed wearing PPE correctly.” from the report
Testing and risk planning
People and staff took part in regular testing. Best-interest decisions and risk assessments were used when someone could not take part.
“People and staff were participating in regular testing. Best interest decisions had been carried out and risk assessments were in place for people who were unable to participate in testing.” from the report
Staff learning
Staff had training about infection risks and protective equipment, and had changed their practices when needed during the pandemic.
“Staff had been proactive in their learning and had implemented changes to practices as needed during the pandemic.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing visits and helping residents keep in touch with their loved ones?
- 02How do you check that staff are still wearing protective equipment correctly?
- 03How are residents and staff currently supported with testing, including people who cannot take part?
- 04What infection prevention and control training have staff completed recently?
- 05How do you support residents who find social distancing or communication difficult?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 8 April 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.
What inspectors found, January 2020
Rated Good overall; inspectors found kind, person-centred care, but the Safe rating Requires Improvement because risk management and recruitment checks were not always strong enough.
This was an unannounced inspection on 7 and 8 January 2020. One inspector spoke with people living at the home, relatives and staff. They also observed care and checked care, medicine, staff and management records.
People were happy and appeared comfortable. Inspectors found kind and respectful relationships, good support for health and independence, and strong links with the local community. Staff had the skills to support people and the home had a positive culture.
The main weaknesses were in the Safe area. Risk records were not always detailed enough, one recruitment record was missing an important risk assessment, and lessons from incidents were not always formally recorded. Oral health records and end of life wishes also needed improvement.
The home was rated Good overall. Safe remained Requires Improvement, while Effective, Caring, Responsive and Well-led were rated Good. The overall rating had improved from Requires Improvement at the previous inspection in January 2019.
Kind relationships
People were treated with kindness and compassion. Staff knew people well and responded quickly when extra support was needed.
“People were treated with kindness and compassion. Staff knew people well and ensured they received the right support.” from the report
Choice and independence
People were supported to make decisions, move freely and take positive risks while managing safety.
“People were supported to be independent. Good procedures were in place to enable people to live their lives in the way they wished whilst managing their safety.” from the report
Community involvement
People attended day centres, social clubs, shops and restaurants, and took part in trips and short breaks.
“People had good links with the community. They attended day centres and social clubs to undertake activities.” from the report
Improving leadership
Inspectors found effective quality checks and a stronger culture of improvement than at the previous inspection.
“Quality assurance measures were effective. Improvements in quality monitoring procedures had led to an increase in the overall quality of care which people received.” from the report
Risk records
needs fixingRisk management needed more consistency. Records about hoarding and behaviours which challenge were not always clear or detailed enough.
“Continued improvements were needed to manage risk. Procedures to manage hoarding behaviours needed clarity. Records to support behaviours which challenge needed to be more detailed in some areas.” from the report
Recruitment check
seriousOne staff recruitment file was missing a key risk assessment. The provider addressed this during the inspection and began an investigation.
“Improvements to recruitment procedures to manage risk were needed. A key risk assessment was missing from one staff recruitment record.” from the report
Incident learning
needs fixingIncidents were reviewed, but important lessons were not always formally recorded. Staff also needed more confidence to challenge ineffective practices.
“Where key incidents took place, a lessons learned approach needed to be more formally recorded.” from the report
Oral health records
minorPeople saw dentists, but records did not fully follow national guidance and support with prescribed toothpastes was not always consistent.
“Support for people with prescribed toothpastes needed to be more consistent.” from the report
End of life wishes
minorStaff had end of life training, but care records setting out people's wishes had not yet been put in place.
“Care records to support people's end of life wishes needed to be put in place.” from the report
- 01What has been done since the inspection to make risk records clearer, especially for hoarding and behaviours which challenge?
- 02How do you now check that every staff recruitment file includes the required risk assessments?
- 03How are lessons from accidents and incidents recorded and shared with staff?
- 04How will you keep records of oral health needs and make support with prescribed toothpastes consistent?
- 05How will you record each person's end of life wishes, and when will this be completed?
This was an unannounced inspection of all five CQC areas, with the Safe and Well-led ratings reviewed against the previous inspection and the other areas remaining Good. This explanation was written from the published report of 23 January 2020 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 Avondale Lodge
8 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- January 2020Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2019Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- June 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- October 2017Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- September 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 January 2011.
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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