CQC report explained · a residential care home
What the CQC found at Avonmere Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2023
Avonmere Care Home rated Requires Improvement; inspectors found medicine safety and management checks were not reliable.
This was an unannounced focused inspection on 13 and 14 July 2023. Inspectors spoke with 16 people, 7 relatives and 11 staff. They observed care and reviewed care records, medicine records, recruitment files and management systems.
The main concerns were medicines, care records, staff training, care planning and management checks. Inspectors found medicine errors and gaps in recording and storage. They said this increased the risk of harm, although they found no evidence that anyone had been harmed at the time of the inspection.
People generally said they felt safe and were happy with the care and staff. Staffing levels, cleanliness, safeguarding procedures and accident monitoring were positive. The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement, and both had fallen from Good at the previous inspection.
People felt safe
People and relatives told inspectors they felt safe. Staff had safeguarding training and knew how to report concerns.
“People told us they felt safe living at the home.” from the report
Enough staff
Inspectors found staffing levels were sufficient and saw staff respond promptly. Recruitment checks included references and criminal record checks.
“There were enough staff on duty to meet people's needs.” from the report
Clean environment
The home and equipment were visibly clean. Staff used protective equipment effectively and cleaning staff worked every day.
“The environment and equipment were visibly clean and Housekeeping staff were on duty 7 days per week.” from the report
Positive relationships
People and relatives spoke positively about the care. Inspectors saw people laughing and joking with staff, and staff said they knew residents well.
“People and relatives were happy with the care provided and spoke positively about the staff who supported them.” from the report
Medicine safety
seriousInspectors found medicines were not always given at the prescribed time. There were also problems with medicine storage, missed deliveries, expired items, patch records and as-needed medicine records.
“The provider had failed to ensure safe systems for the management and administration of medicines.” from the report
Care records did not always guide staff
needs fixingSome records did not give enough information about how to manage risks such as seizures and choking. Records about stoma care and some other care were also inconsistent.
“Information about risks and safety was not always comprehensive or up to date.” from the report
Management checks missed problems
needs fixingThe home's audits and governance systems did not identify several of the problems found during inspection. This meant leaders did not have a reliable picture of care quality and safety.
“These were not always effective as they did not identify the shortfalls we identified during this inspection.” from the report
Infection control practice
minorSome staff wore nail varnish, gel nails or false nails. Inspectors said this did not follow good infection prevention practice, although other infection control measures were in place.
“We observed some staff members wearing nail varnish and/or gel nails.” from the report
- 01What specific changes have been made to ensure time-specific medicines are given at the prescribed times?
- 02How are medicines for people who self-administer checked, counted and stored securely?
- 03How do you now check that care plans give staff clear instructions for seizures, choking and stoma care?
- 04What evidence shows that medicine audits and other management checks now identify problems promptly?
- 05What action has been taken about staff wearing nail varnish, gel nails or false nails?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; no ratings were given for Effective, Caring or Responsive in this report. This explanation was written from the published report of 14 September 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, July 2021
Avonmere Care Home was inspected but not rated; inspectors were assured about infection control and visiting arrangements.
This was an announced, targeted inspection on 16 June 2021. It looked at how the home prevented and controlled infection during the coronavirus pandemic.
Inspectors were assured that the home used personal protective equipment safely, supported testing, followed social distancing and shielding guidance, and admitted new residents safely. They also found the home exceptionally clean, with infection control policies, audits and staff training in place.
Family visits were supported under current government guidance. People and families were kept in contact during the pandemic, and staff provided extra one-to-one wellbeing support. The service was inspected but not rated, so this report does not give a Good or Outstanding rating.
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infection, including current policies, audits and staff training.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Clean environment
The home was described as exceptionally clean. Staff paid attention to frequently touched surfaces and supported hand washing.
“The head housekeeper and their team contributed to keeping people safe during the pandemic.” from the report
Family visits
The home supported visits in line with current guidance. Visitors were told what to expect, tested before entry and guided to the visiting area.
“Prior to any visiting people were informed of the procedures they should expect on arrival.” from the report
Emotional support
The home maintained contact between people and their families during the pandemic. Staff increased one-to-one wellbeing support and continued activities.
“One to one wellbeing interaction with people had increased and people had enjoyed this individualised approach in addition to the activity programmes.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection control and visiting arrangements are in place now, and how do they differ from those inspected in June 2021?
- 02How are visitors currently tested and supported to follow infection control procedures?
- 03How would the home manage an infection outbreak or a new admission who needed to self-isolate?
- 04How is one-to-one wellbeing support provided now, especially for people who find restrictions difficult to understand?
- 05What are the home’s current ratings for Effective, Caring, Responsive and Well-led, as these areas were not assessed in this report?
This was an announced, targeted inspection of infection prevention and control during the coronavirus pandemic; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 9 July 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 Avonmere Care Home
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021Inspected but not ratedSafe: Inspected but not rated
- August 2018GoodSafe: GoodWell-led: Good
- August 2017
Registered with the Care Quality Commission on 23 August 2017.
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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Most charge £1,020 to £1,280 a week. 32 can care for a couple. 11 years' experience on average.
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