Avocet Court

Updated 15 June 2022

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 Health and Social Care Act 2008.

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 one inspector.

Service and service type

Avocet Court is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Avocet Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was not a registered manager in post. There was a manager who had completed a registered manager application, which was being processed by Care Quality Commission at the time of our inspection.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We visited the service on 13 May 2022. We spoke with nine staff members including the manager, the clinical lead staff member, the operations director, care, nursing, maintenance and domestic staff. We spoke with 10 people who used the service and three relatives. We also observed people using the service and their interactions with staff. We reviewed a range of records including health and safety and audits during our visit. We asked the manager to send us further records securely for us to review remotely.

Following our visit, we reviewed records including five people’s care records and records relating to how the service seek feedback from people and the service’s ongoing improvement plan. We received electronic and telephone feedback from four relatives and eight staff members.

On 26 May 2022 we fed back our findings from the inspection by video call to the manager, clinical lead and operations director.

Updated 15 June 2022

About the service

Avocet Court is a residential care home providing personal and nursing care to up to 153 people. The service provides support to adults. The service also provides support and care to people when they have left hospital and need additional support to go home, referred to as ‘discharge to assess’. At the time of our inspection there were 89 people using the service.

The service accommodates people across three separate units, each of which has adapted facilities. These were, Cilgerran House and Powys House, which provided personal and nursing care, and Harlech House which provided personal and nursing care for people living with dementia. There was a separate unit, where the management team, reception and administration, kitchen, coffee shop and laundry were located.

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

Since our last inspection, there had been a change in management of the service. Staff and relatives were positive about how the service was led and that the manager was approachable.

There were systems in place to provide people with a safe service. Lessons were learned when incidents and accidents occurred, and actions taken to reduce them happening again in the future. Staff were trained and guidance provided in people’s care records in how to keep people safe from abuse and avoidable harm.

People received their medicines where required and safely. Staffing levels were calculated to reduce the risks of people not receiving the care they required. These were kept under review and were adjusted where needed.

Infection control processes and procedures were in place to reduce the risks of cross infection. The service followed the most up to date guidance relating to the pandemic, this included the provision of personal protective equipment (PPE) for staff and testing. Visiting was managed safely which supported people to maintain relationships with their family and friends.

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.

The governance systems in place supported the management team to assess and monitor the service provided and identify and address any issues identified. The management team were knowledgeable about their role and responsibilities and what was happening in the service. People’s views were listened to and used to drive improvement.

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 2 October 2021). We found a breach of regulation relating to the governance systems in place for monitoring and assessing the service provided.

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.

At our last inspection we recommended that the provider seek advice from a reputable source on their infection control procedures and the use of slings. At this inspection we found improvements had been made, people had their own slings and people staying in the service using the discharge to assess service were provided with disposable slings, all which reduced the risks of cross infection. We also recommended the risks associated with unguarded surfaces such as pipes and radiators required more detail in risk assessment to demonstrate effective oversight. At this inspection we saw records which evidenced that the areas were regularly checked and monitored to ensure people were safe.

Why we inspected

We carried out an unannounced focused inspection of this service on 23 August 2021 (published 2 October 2021). A breach breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve in their governance processes. We also made two recommendation in relation to safe care and treatment.

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

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.