CQC report explained · a residential care home
What the CQC found at Avondale Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found effective safeguarding systems, enough staff, safe recruitment and risk assessments for people's individual needs. Medicines were safely stored, administered and checked.
- Effective?
- Good
- People's needs were assessed and care was planned around them. Staff had relevant training and support, and people had access to food, drink and healthcare professionals.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. They knew people's life histories and preferences and encouraged people to remain independent.
- Responsive?
- Good
- Care plans were personalised and reflected people's needs and choices. People could take part in activities, access the community and raise complaints or concerns.
- Well-led?
- Good
- Management was described as open and approachable, with audits, staff training checks and feedback systems in place. This rating improved from Requires Improvement at the previous inspection.
What inspectors found, December 2019
Rated Good; inspectors found safe, kind and personalised care, with well-led management improving from the previous inspection.
This was an unannounced, planned comprehensive inspection on 24 October 2019. One inspector reviewed care records, medicines, staffing, training, incidents, complaints and management checks. They spoke with five people, two relatives and members of staff.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitably recruited staff, safe medicines systems, personalised care, good access to health professionals and a clean environment.
People and relatives said staff were kind, respectful and responsive. Staff knew people's needs and preferences, supported independence and helped people take part in activities. Complaints and concerns were listened to and acted on.
The overall rating remained Good, as it was at the previous inspection in 2017. The Well-led rating improved from Requires Improvement to Good.
Kind and respectful care
People were supported by staff who built caring relationships and treated them with dignity and respect.
“People received care from staff who developed positive, caring and compassionate relationships with them.” from the report
Personalised support
Care plans recorded people's specific needs, preferences and the way they wanted to be supported.
“Care plans were personalised to the individual and recorded details about each person's specific needs and how they liked to be supported.” from the report
Safe staffing and medicines
Inspectors found enough staff, safe recruitment checks and systems to support safe medicines administration.
“There were sufficient numbers of staff to meet people's needs.” from the report
Improved management
The Well-led rating improved from Requires Improvement to Good. Management used audits, staff feedback and training checks to monitor the service.
“At this inspection this key question has improved to good.” from the report
Clean environment
The home was reported to be clean and free from unpleasant odours, with staff following infection control practices.
“When I visit the home is clean and tidy” from the report
Inspectors raised no specific concerns in this report.
- 01How have staffing levels and the consistency of the staff team changed since the inspection?
- 02How will you update my relative's care plan when their health, communication needs or preferences change?
- 03How do you involve relatives in decisions about care and in responding to concerns?
- 04What activities and community access would be available for my relative, based on their interests and abilities?
- 05How do you check that medicines are being given safely and that staff remain competent?
This was a planned comprehensive inspection covering the premises and care provided, with all five CQC questions rated. This explanation was written from the published report of 4 December 2019 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, April 2017
Rated Good overall, with safe and caring support, but the home’s quality checks and reporting systems require improvement.
This was an unannounced inspection on 13 February 2017. One inspector, a pharmacist and an expert by experience visited the home. They spoke with people living there, relatives, staff, the manager and the provider. They also reviewed care files, medicines records, recruitment and training records, complaints and quality checks.
Inspectors rated Safe, Effective, Caring and Responsive as Good. People felt safe and said staff were kind, respectful and helpful. Staff were trained and supported, people were involved in decisions where possible, and care was planned around people's needs and preferences.
The home was rated Requires Improvement for Well-led. Quality audits were not detailed enough to identify patterns or trends, and some accidents and incidents had not been reported to the CQC as required. The home had improved its medicines management and recruitment checks since the previous inspection, but some medicines records still needed attention.
The overall rating was Good. This means inspectors found the main areas of care to be meeting the expected standard at the time of the inspection, while the management and checking systems needed to become more reliable.
Safer medicines management
Medicines management had improved since the previous inspection. Inspectors found suitable storage, completed administration records and appropriate stock arrangements.
“People we spoke with also told us that they received their medicines when they should and that they were given appropriately.” from the report
Kind and respectful care
People and relatives described staff as kind, polite and caring. Inspectors saw staff protecting people's dignity and responding reassuringly when someone became distressed.
“Staff maintained people's dignity and provided respectful care.” from the report
Trained and supported staff
Staff had an induction, ongoing training, supervision and appraisals. They demonstrated the skills needed to support people safely.
“Staff had the skills and knowledge required to support people effectively.” from the report
Personalised support and activities
Care plans included people's likes, dislikes, hobbies and interests. Staff offered activities such as singing, bingo, quizzes and outings where possible.
“Staff understood people's needs and provided specific care.” from the report
Quality checks were not robust
needs fixingAudits covering skin care, falls and safeguarding were not detailed or comprehensive enough. This meant the home could miss patterns or trends needing action.
“Quality assurance audits were not carried out robustly, so that it was unclear if any patterns or trends were developing which may impact upon the service provided to people.” from the report
Some medicines records needed improvement
needs fixingEye drops were not always dated when opened, so staff could not always tell whether they were safe to give. Instructions for some 'when needed' medicines also needed to be more personal and detailed.
“Medicines with short expiry dates once opened, such as eye drop preparations, were not always dated when opened.” from the report
Incident reporting was inconsistent
needs fixingThe provider had not consistently notified the CQC about accidents and incidents that were required to be reported. The manager received clarification and agreed to send future and retrospective notifications.
“We found that some, but not all notifiable events had been shared with us.” from the report
- 01What changes have you made to quality audits for falls, safeguarding and skin care since this inspection?
- 02How do you now make sure all accidents and incidents that must be reported are notified to the CQC?
- 03How are eye drops dated when opened, and how do you check that they are still safe to use?
- 04How are instructions for 'when needed' medicines written around each person's individual needs?
- 05What are the current staffing levels, especially on the 3pm to 10pm shift, and how often are agency staff used?
This was an unannounced inspection of the overall service, covering all five CQC questions and including observations, interviews and checks of care, medicines, staffing and management records. This explanation was written from the published report of 26 April 2017 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 Residential Care Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- December 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Avondale Residential Care Home →
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Avondale Residential Care Home →
- April 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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