Background to this inspection
Updated
2 December 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection team consisted of two inspectors.
Service and service type
Avalon Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed the information we held about the service and the service provider. We looked at notifications and any safeguarding alerts we had received for this service. We sought feedback from the local authority and professionals who work with the service. Notifications are information about important events the service is required to send us by law.
The provider was asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all this information to plan our inspection.
During the inspection
We looked around the service and met with the people who lived there. We used the Short Observational Framework for Inspection (SOFI) during the morning of the first day of our inspection. SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We spoke with nine people to understand their views and experiences of the service and we observed how staff supported people. We spoke with the registered manager, and seven further staff members. This included care staff, housekeeping, administrative, catering staff and maintenance staff.
We reviewed the care records of five people and a range of other documents. For example, medicine records, three staff recruitment files; staff training records and records relating to the management of the service. We also looked at staff rotas, and records relating to health and safety.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We spoke with three relatives and four health care professionals and completed these discussions on 01 November 2021.
Updated
2 December 2021
About the service:
Avalon Nursing Home provides nursing and personal care for up to 38 older people, some of whom were living with a dementia type illness. There were 32 people living at the home at the time of the inspection. In addition to living with dementia people had a range of complex health care needs which included stroke and diabetes. Most people required help and support from two members of staff in relation to their mobility and personal care needs.
People’s experience of using this service and what we found:
Systems and processes to assess, monitor and improve the quality and safety of the service provided were in place. However, there were areas of people’s documentation that needed to be improved to ensure staff had the necessary up to date information to provide consistent, safe care. Staff practices regarding medicine practices needed to be further developed to ensure that staff follow the organisational policy for safe administration of medicines. Oral health was found not be consistently monitored to ensure good practice was consistently followed.
People received safe care and support from staff who had been appropriately recruited, trained to recognise signs of abuse or risk and understood what to do to safely support people. One person said, “I feel as if I get good care, I do feel comfortable here.” A visitor told us, “My relative is happy here, the staff are very good with her, we are pleased with the care.” People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible. There were enough staff to meet people's needs, but staff deployment at busy times needs to be reviewed. Safe recruitment practices had been followed before staff started working at the service.
The provider and registered manager were committed to continuously improve and had developed structures and plans to develop and consistently drive improvement within the service and maintain their care delivery to a good standard.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update:
The last rating for this service was Good (published 4 February 2020)
Why we inspected
This inspection was prompted due to information of risk and concern in relation to staffing levels, communication and safeguarding concerns which had impacted on care delivery. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
The concerns raised were looked at during this inspection and have been reflected in the report.
We have found evidence that the provider needs to make improvements. Please see the well-led question of this full report.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Follow up:
We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.