CQC report explained · a residential care home
What the CQC found at Avondene Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2021
Inspected but not rated; inspectors found improved governance and that the previous Regulation 17 breach had been resolved.
This was an unannounced, targeted inspection on 14 April 2021. It checked whether the home had met a Warning Notice about its management and quality systems. The inspector spoke with four staff members, received feedback from two people and reviewed records and audits.
Inspectors found that quality checks were now working effectively. These included checks on infection control, health and safety, medicines, accidents and incidents. Actions were identified, completed and monitored.
The home was no longer in breach of Regulation 17. However, this inspection did not review the whole service or change its previous rating. The overall rating and the well-led rating remain requires improvement from the last inspection.
Improved quality checks
The home had introduced working audits covering areas such as infection control, health and safety, medicines and accidents.
“Improvements to quality assurance systems meant they were operating effectively.” from the report
Actions were followed through
Inspectors found that actions from audits were completed and that the registered manager monitored progress.
“Actions had been identified from audits and the person responsible had carried out the action to completion, this had been monitored by the registered manager.” from the report
Staff confidence
Staff described positive changes and said they had confidence in the registered manager.
“Staff told us they had confidence in the registered manager.” from the report
Provider support
The provider had systems for supporting and monitoring the home through visits, video calls and telephone calls.
“The provider had a system in place for supporting and monitoring the home.” from the report
Full service not reassessed
needs fixingThe inspection covered only the specific governance concerns in the Warning Notice. The previous requires improvement rating remains in place until a comprehensive inspection reviews the wider service.
“We will assess all of the key question at the next comprehensive inspection of the service.” from the report
- 01How are the infection control, medicines, health and safety, and accident audits being kept up to date?
- 02What recent patterns or learning have been identified from accidents and incidents?
- 03How does the provider now support and monitor the home between inspections?
- 04When is the next comprehensive inspection expected to review the full service?
- 05How are staff being supported to maintain the improvements in organisation and governance?
This was a targeted inspection of specific governance concerns linked to Regulation 17; it did not assess the whole service, and the previous ratings were not changed. This explanation was written from the published report of 30 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, March 2021
Targeted inspection found improvements in safety, but the home remained rated Requires Improvement overall and was not fully re-rated.
The inspection was unannounced and took place on 10 February 2021. One inspector spoke with two residents and two staff members, observed the home, and checked care, medicines and management records.
Inspectors found improvements since the previous inspection. Risks were assessed, medicines were managed safely, and infection control arrangements, cleaning, visitor procedures and PPE had improved. The home was no longer in breach of Regulation 12.
This was a targeted inspection, not a full review. The overall rating therefore stayed Requires Improvement from the previous inspection. The Safe question was inspected but not rated.
Improved infection control
Infection control procedures had been reviewed and improved. Inspectors were assured about PPE, visitor safety, testing, cleaning and outbreak arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safer medicines management
Medicines were stored safely, and room and fridge temperatures were checked. Instructions for occasional medicines had also improved.
“Improvements had been made to the management of medicines and they were now managed safely.” from the report
Risk assessments
People had individual risk assessments covering all aspects of their care and support. Risks around the home were also monitored through monthly audits.
“People had individual risk assessments in place for all aspects of their care and support.” from the report
Improved cleaning
The home had increased cleaning to three times a day, including high-touch areas.
“Cleaning within the home had improved, the registered manager told us they had increased this to three times a day to include high touch point areas.” from the report
Overall rating still Requires Improvement
minorThe home kept its previous overall Requires Improvement rating because this visit was targeted and did not reassess the whole service.
“Targeted inspections do not change the rating from the previous inspection.” from the report
- 01What actions have you taken since the inspection to improve the areas not covered by this targeted visit?
- 02How do you check that individual risk assessments remain up to date when a resident's needs change?
- 03How are medicines that residents take only occasionally recorded and checked now?
- 04How often are high-touch areas cleaned, and how is this checked?
- 05When is the next comprehensive CQC inspection expected?
This was a targeted inspection of specific parts of Safe, including risks, medicines and infection control; it did not assess the whole service, and the other areas were not re-rated. This explanation was written from the published report of 5 March 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 Avondene Care Home
5 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- April 2021Inspected but not ratedcurrent ratingWell-led: Inspected but not rated
- March 2021Inspected but not ratedSafe: Inspected but not rated
- January 2021Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2019Goodup from Requires improvementSafe: GoodCaring: GoodWell-led: Good
- November 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 24 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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