CQC report explained · a residential care home
What the CQC found at The Avenues Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks were not assessed or managed properly. Medicines were not always managed safely, staffing was sometimes insufficient, and recruitment and training checks were incomplete.
- Effective?
- Requires improvement
- This key question was not inspected in this report. Its previous rating was used to calculate the overall rating.
- Caring?
- Requires improvement
- This key question was not inspected in this report. Its previous rating was used to calculate the overall rating.
- Responsive?
- Requires improvement
- This key question was not inspected in this report. Its previous rating was used to calculate the overall rating.
- Well-led?
- Requires improvement
- Management checks did not identify important problems. The home did not consistently act on feedback, communicate important information or create a respectful and open culture.
What inspectors found, March 2023
The Avenues Care Centre was rated Requires Improvement; inspectors found risks with care planning, medicines, staffing and management checks.
This was an unannounced focused inspection. Inspectors visited on 23 January 2023 and checked whether earlier improvements had been made. They spoke with people, relatives and staff, observed care, and reviewed care, medicine, recruitment and management records.
The home was not always safe. Some risks had not been assessed or explained to staff, one person had no care plan for epilepsy, and medicines were sometimes given late or not managed safely. Staffing levels were below the assessed need on 18 of 28 days reviewed. Some staff also lacked important training and recruitment checks.
Management was not consistently effective. Audits had missed serious shortfalls, feedback was not gathered and acted on well, and some incidents were not reported to CQC. The provider sent an action plan after the inspection, but the home remained in breach of several regulations.
The overall rating and the ratings for Safe and Well-led were Requires Improvement. The other three key questions were not inspected in this report, so their previous ratings were carried forward.
Kind and caring staff
People and relatives said staff were kind and caring. Inspectors also saw most staff supporting people in caring ways.
“People and their relatives told us the staff were kind and caring.” from the report
Action after accidents
Inspectors found that the home took action after falls and referred people to a falls clinic when needed. Extra equipment was provided to help keep people safe.
“Effective action was taken to learn lessons when things went wrong and prevent them from occurring again.” from the report
Visitors were welcomed
There were no restrictions on visits. Relatives said they could visit regularly and spend as much time as they wished with their loved one.
“There were no restrictions on people receiving visitors.” from the report
Risks and care plans
seriousSome risks were not assessed or explained to staff. One person had no care plan for epilepsy, and guidance was missing for another person's diabetes and for some moving and handling needs.
“No care had been planned for 1 person with epilepsy.” from the report
Medicines
seriousSome medicines were crushed in a way that could make them less effective or cause side effects. Doses were sometimes given too close together, and medicines were delayed when staffing was limited.
“Medicines were not always administered in line with the prescribers intentions or safety requirements.” from the report
Staffing, training and recruitment
seriousSome shifts had fewer care staff than the home had assessed as necessary. Several staff lacked required checks or training, including training about dementia, diabetes and epilepsy.
“Five care staff working at the service did not have a Disclosure and Barring Service (DBS) check in place.” from the report
Weak management checks
seriousAudits did not identify important problems, and care plans and risk assessments were not always reviewed. The leadership team did not have enough oversight of delegated work.
“Checks and audits completed had not been effective and the registered manager and provider were unaware of the shortfalls in quality and safety we found.” from the report
Feedback and respect
needs fixingThe home had not found effective ways to hear from people and relatives or explain what it had done in response. Inspectors also found that people were not always referred to respectfully.
“Effective action had not been taken to gather and act on the views of people and their relatives.” from the report
Infection guidance
needs fixingThe home had not assessed infection risks for some people who were more vulnerable. The manager was also unaware of changes to national guidance about face masks.
“Risks to people had not been assessed and action planned to keep these people as safe as possible.” from the report
- 01What has been done to make sure every person has an up-to-date risk assessment and care plan, including for epilepsy, diabetes and moving safely?
- 02How do you now prevent medicine delays, unsafe crushing of medicines and doses being given too close together?
- 03How many trained staff are planned for each shift, and how do you cover vacancies without delaying care or medicines?
- 04Have all staff now had the required DBS, employment history and previous care employment checks?
- 05How are you checking that audits, care plan reviews and feedback now lead to prompt action?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the last comprehensive inspection. This explanation was written from the published report of 4 March 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, June 2022
The Avenues Care Centre: Rated Requires Improvement; inspectors found better staffing and medicines management, but risks and quality checks were still not managed well enough.
This was an unannounced focused inspection on 27 April 2022. Inspectors checked whether the home had improved its safety and management after the previous inspection. They spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
There had been improvements. Staffing levels were better, call bells were answered promptly, recruitment checks were safe and medicines were generally managed safely. People and relatives were positive about the care and communication. Staff were also positive about the new manager.
However, some care plans did not give staff enough guidance. Staff records had gaps, including records about repositioning people and checking pressure-relieving mattresses. Blood sugar testing equipment was not calibrated regularly, and some areas needed deeper cleaning.
The overall rating remained Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used. The home remained in breach of regulations about safe care and good governance.
Improved staffing
Staffing levels had improved and call bells were answered promptly. The home was no longer in breach of the staffing regulation.
“At this inspection call bells were answered promptly.” from the report
Medicines management
Medicines records were clearer, stock counts matched the records and medicines were stored safely. The home was no longer in breach regarding medicines management.
“At this inspection the safety of medicine administration had improved.” from the report
Positive care experience
People and relatives gave positive feedback about the care, respect and communication they received.
“[My relative] is safe and very well looked after. The staff are all very respectful and so lovely.” from the report
Learning from incidents
The manager monitored incidents and accidents for patterns and took action where trends were found.
“Where trends were identified, action was taken.” from the report
Involving families
Relatives had opportunities to give feedback and were contacted when there were concerns or incidents.
“They are very, very good at involving me in decisions about [my relative].” from the report
Incomplete risk guidance
seriousSome care plans did not contain enough information for staff to manage risks safely. This included diabetes guidance and support for a person who refused diabetes medicines.
“The provider had failed to ensure all risks to people were assessed and mitigated.” from the report
Unsafe staff practice
seriousOne person who was unsteady was left in an unsafe position while waiting for assistance. Staff practice still needed improvement.
“They left the person in an unsafe position when they should have used their walkie talkie to communicate to other staff they needed assistance.” from the report
Poor care records
needs fixingRecords did not always show that planned care had been provided. There were gaps in repositioning records and insufficient detail about mattress checks.
“There were gaps in records. For example, there were gaps in one person's records to show they had been repositioned in line with the care plan to reduce the risk of pressure sores.” from the report
Weak quality checks
seriousAudits had identified some concerns, but action had not been completed in all areas. This meant risks remained.
“The provider had failed to ensure checks and audits had driven forward improvements at the service.” from the report
Other safety shortfalls
needs fixingThe blood sugar testing machine was not calibrated regularly. A small number of areas also needed deeper cleaning, and some staff were still completing training.
“This machine was not being regularly calibrated. We raised this with the registered manager as an area for improvement.” from the report
- 01How have you completed the outstanding improvements to care plans and risk assessments?
- 02How do you make sure blood sugar checks are completed consistently when a person refuses diabetes medicines?
- 03How do managers check that staff records accurately show repositioning and pressure-relieving mattress checks?
- 04Has the blood sugar testing machine been regularly calibrated since the inspection?
- 05What action has been completed following the breaches of Regulations 12 and 17?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 15 June 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.
Every inspection of The Avenues Care Centre
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2021Requires improvementstayed Requires improvementSafe: InadequateWell-led: Requires improvement
- March 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2017Goodstayed GoodSafe: Good
- May 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2012
Registered with the Care Quality Commission on 30 January 2012.
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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