St Matthews Limited - The Avenue

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 leadership, 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 Good. At this assessment the rating has remained Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had a defined set of organisational values. Staff feedback reflected these values in practice. One staff member told us, “It’s a good company to work for.” Another said, “It’s a nice company to work for.” A further staff member commented, “They are supportive and want you to be able to do a good job.”

Staff spoke positively about changes implemented over the last 12 months, describing how these had strengthened the culture of the organisation and created a more supportive and engaging working environment.

We saw minutes to confirm the Managing Director and Chief Operating Officer visited the service and held introduction sessions when they first joined the organisation. We saw the senior leadership team shared a weekly bulletin that included important updates. For example, one bulletin included information in relation to freedom to speak up and weather warnings.

The provider listened to and involved staff through their annual satisfaction survey. The provider shared the last survey for the home and although there was a need to increase the engagement of the staff team in subsequent surveys; this included an analysis of findings and where there were areas for improvement, actions had been identified.

Staff were aware of the senior leadership team and their roles within the organisation. They told us that leaders, including the Director of Operations, Chief Operating Officer, Managing Director and Chair, visited the home regularly, which helped ensure visibility and accessibility of leadership.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Feedback about the Registered Manager from staff, people and their relatives was generally positive. Staff told us, “[Manager] is supportive and approachable. You feel you are being listened to and [manager] wants the best of us and the residents.”

A relative told us, “Yes – I know the manager, [they] are always available for a chat or to ask advice.” Other relatives told us, “I have met the manager I think [manager] is doing a good job,” and “It seems very well run, the staff seem happy which is encouraging.”

There had been a significant change in the provider’s leadership team over the last 12 months and staff told us this had been a positive change. Staff told us the new senior leadership team were approachable and no longer felt they could not bring their whole self to work.

We observed the registered manager knew people well and was able to describe people’s needs. The registered manager told us they attended regular management team meetings with the provider and other registered managers.

Although we did not find all visits from the provider’s representatives had been effective, we found the Registered Manager and Chief Operating Officer receptive to all the feedback we shared during the assessment. The Chief Operating Officer’s approach motivated staff to deliver the best possible care and we saw this reflected in the confidence of staff during our assessment.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

There was a whistleblowing policy and freedom to speak up information was displayed around the home. There was a freedom to speak up guardian and staff told us there had been significant improvement in the provider’s culture. This meant people were more inclined to raise concerns and their voice be heard.

During our assessment we shared with the provider that not all staff had been able to tell us about the provider’s approach to speaking up, including how to raise a whistleblowing concern or who to contact. We saw the provider share learning from this immediately to remind all staff how they were able to access support.

Although not all staff were able to tell us about the provider’s whistleblowing policy, we were assured that the information was on display across the service and accessible and staff told us how they could contact the local authority or CQC with concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.
 

The provider has a equality, diversity and inclusion strategy that had been introduce in 2025 covering areas for development over a 3 year period, including foundation and compliance, (Year 1), embedding and culture change (Year 2) and maturity and excellence (Year 3).

Staff completed equality and diversity training. We found there was a diverse workforce where staff were positive about working at the service and felt they were treated with respect.

Staff told us they were inducted to their role and there were plenty of opportunities to progress within the organisation. For example, the provider had previously introduced an assistant practitioner role to support registered nurses. The assistant practitioner posts enabled staff to develop further knowledge, skills and experience through delegation and potentially work towards nurse education in the future.

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.

The provider had systems and processes in place to monitor and improve the quality of care being delivered. For example, there was a schedule of governance audits that were completed on a regular basis, including daily, weekly and monthly. Although we found the provider had identified some of the improvements we identified during the assessment, checks and audits had not identified all the areas for development we found. For example, audits had not identified the need to improve medicines protocols or the mealtime experience.

The Registered Manager and Chief Operating Officer were receptive to our feedback throughout the assessment and were able to see immediately improvements being made to strengthen governance arrangements. For example, the daily walkaround audit was enhanced.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff worked with external agencies to ensure people could access the health and social care services they needed. A visiting external professional we spoke with during our assessment told us, “You are always welcomed to the home, and the staff and management are approachable people.” Another professional told us, “They seem to know the patients well and listen to our advice and guidance.”

The provider completed an annual stakeholder satisfaction survey to get feedback from partners and we saw evidence this had been completed in the last 12 months, describing the services strengths, celebrations and opportunities for improvement.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider recognised the importance of learning lessons from incidents, audits and feedback, as an opportunity to improve the service and people’s quality of life. We found there was a quarterly lessons learnt log and a ‘you said, we did’ approach towards learning. The provider had several strategies to aid their development, for example, a nursing strategy 2025-2026.

The provider has developed some internal accreditation schemes to help the service work towards continuous improvement. For example, there was an internal safeguarding accreditation framework and different levels of accreditation the service could work toward to demonstrate their commitment to best practice, continuous improvement, and resident well-being.

The provider has a service improvement plan and the registered manager showed us how they monitored this, but were able to allocate specific actions to a staff members and see how these progressed within specific timeframes.

The management team responded openly and proactively to our feedback about the areas for improvement we identified during the assessment and took action to address each one and provider us with a learning log. For example, the action they planned to take in relation to our feedback about how the staffing tool could be further developed. This further evidenced a culture of continuous learning, innovation and improvement.