Advent House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service managership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained as requires improvement.

This meant the management and managership was inconsistent. Managers and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people.

There was no robust monitoring of actions taken from audits. For example, people using the service completed a questionnaire about their bedrooms, but issues noted in October were still mentioned in January 2026 and managers were unsure if actions had been taken. There were several gaps within care and treatment records, and most risk assessments had not been updated since August 2024, despite changes in need. . There were gaps in handover documents, continence management, seizure monitoring, weight management, repositioning information was not always completed, food and fluid take for people was not always monitored or documented which meant people were at risk of lack of monitoring with their care and treatment.

There was a poor culture between the day and night staff especially around cleaning tasks. This resulted in unclean premises at the service which meant people using the service had an unclean home. A staff member said, “Management need to bring day and night staff together for meetings”.

Not all managers understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Managers did not always have the skills, knowledge, experience and credibility to lead effectively.

There was a lack of consistent and effective managership and governance to continually evaluate the service and lead sustained improvement. The provider failed to assess, monitor, and mitigate the risks relating to the health, safety and welfare of people who used the service. Managers completed daily walk arounds, however there was no evidence of these being completed.

There was no evidence to support management had consistently completed audits for care and treatment records as there were shortfalls in documentation. This meant management could not identify gaps and issues within people’s care and treatment records.

There was a lack of robust systems in place for monitoring the cleanliness of the service. Infection control audits showed repeated issues in terms of cleanliness for the service and these issues were still present at the time of inspection.

The provider had a whisleblowing policy in place, however, staff did not always feel they could speak up and that their voice would be heard. There were shortfalls in governance systems which meant we were not assured all concerns were listened to, monitored and address. There were mixed reviews about speaking up. The provider had a process for speaking up, and some staff gave examples they could raise concerns with managers and be heard. Some staff felt they had raised issues and were not heard.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider did ensure there was diversity amongst the workforce. Staff gave examples of reasonable adjustments that had been made to support staff. However, not all staff felt supported by the management team and there was mixed feedback about the management team. Managers did not always provide staff with robust opportunities for development. Staff had limited access to supervision, appraisals and team meetings which meant staff were not supported in their roles effectively.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was a lack of oversight from managers within the service. Quality assurance checks were inconsistent, and the managers failed to establish effective systems to assess, monitor and improve the quality and safety of the service. This placed people are risk of harm. We identified regulatory breaches relating to person-centred care, medicines, safeguarding people from abuse and governance systems. Since the inspection the provider have provided evidence they were making improvements following our concerns.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider did not raise all safeguarding concerns with CQC. Safeguarding logs kept by management were incomplete and managers did not have access to a safeguarding concern raised in August 2025.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The service did not seek feedback from people living in the homes or their relatives and from staff.