Avalon Nursing Home

Updated 18 September 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 was undertaken by an inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

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 used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with eight people who used the service and four relatives about their experience of the care provided. We spoke with six members of staff including the registered manager, deputy manager, care workers, Mental Capacity Act Lead and registered nurse. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We received feedback via email from two professionals and five relatives.

Updated 18 September 2021

About the service

Avalon Nursing Home is a nursing home providing personal and nursing care to 47 people at the time of the inspection. The service can support up to 55 people. Accommodation is laid out over two floors, both floors incorporate private bedrooms, with some offering walk-in showers. All bedrooms have ensuite facilities. The ground floor provides level access to a garden, with patio and outdoor dining furniture. There is additional outside space in the form of a small courtyard adjacent to the large communal lounge. Smaller lounges and seating areas are available throughout the home. The registered manager’s office is located next to the main reception area.

People’s experience of using this service and what we found

People received safe care and were protected from potential abuse. People told us they felt safe and relatives confirmed this. Since our last inspection, the service had introduced measures to improve the safety of care provided, including in relation to pressure ulcer management. There were sufficient numbers of staff deployed across the service to meet people’s needs. Medicines were managed safely, and measures were in place to prevent the spread of infection. Lessons were learnt when things went wrong.

Staff, people, and relatives spoke positively about the management team. Since our last inspection, the service had made changes to ensure quality assurance systems were used effectively and routinely, to identify concerns errors and omissions. The service was introducing initiatives and looking to develop care provision by working with external organisations and gaining accreditations. Feedback was sought from people, their relatives and stakeholders. The service provided people with person-centred care and the staff worked as a team. The provider was working in line with regulatory requirements.

People received effective care and experienced good outcomes. Since our last inspection, improvements had been made to ensure people consented when they needed care and treatment. When people could not consent, the service worked in line with the principles of the Mental Capacity Act (MCA). Staff were passionate about ensuring people were empowered to make their own decisions and take risks. People were supported to eat and drink enough, and their needs were assessed in line with published guidance. Staff received support and training relevant to their roles and the people they supported.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 Requires Improvement (published 05 July 2019) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Avalon Nursing Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.