Sidney Avenue Lodge Residential Care Home

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 changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We found no evidence that people had been harmed. However, systems were either not in place or robust enough to demonstrate safety was effectively managed. This placed people at risk of harm. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (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.

Sidney Avenue is a small family run home and there was an atmosphere of inclusivity within the home. People had been living at the home for a number of years and knew each other well. Staff had similar backgrounds and spoke the same language as people living at the home. People were viewed as individuals which promoted equality and inclusion. Staff understood challenges people with a learning disability faced and supported people to maintain as much independence as possible. The registered manager supported this vision of care which was evident throughout the inspection.

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.

Staff were positive about the registered manager and how they were supported in their role. One staff member commented, “[Registered manager] is not just a good manager, but he is a very good person.” Another staff member felt the support from the registered manager was good but felt they should be more involved in paperwork and people’s reviews. At the time of the assessment the registered manager did not have a deputy or senior to help with paperwork. This meant paperwork was not always completed as other aspects of care delivery were being focused on.

We discussed this with the registered manager who said they were planning to train a senior member of staff to support them.

Relatives were positive about the care and leadership at the home. One relative said, “In essence, they are doing a five-star job and I commend all the staff in that home, and they are running it so well. You have to have that quality.”

Prior to July 2025, the registered manager confirmed there had been staff meetings, but these were not documented. There were monthly staff meeting minutes from July 2025 and August 2025 meeting minutes showed staff had input, and suggestions were taken on board, discussed and actioned where necessary.

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

Staff knew what whistleblowing was and how to raise any concerns. Staff felt able to voice any concerns they had and were confident these would be addressed.

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 home had a small staff team and diversity was reflected in the staff employed. Staff were able to speak Greek and English which ensured people were able to fully express their needs and feel understood.

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 local authority had completed a quality assurance visit in July 2025 and found there was a significant lack of auditing processes and governance. Auditing processes allow the provider to have oversight of the quality of care and helps identify any issues or concerns. During the assessment we found some audits were in place around the environment of communal areas and people’s bedrooms. However, these did not state if issues were found or how any concerns would be addressed. There were no medication audits completed, just a stock check of medicines. The registered manager confirmed there were no audits in place prior to July 2025 for approximately two years.

We also found care plans had not always been updated, menus, staff meetings, staff supervisions and documentation around activities was also not adequately in place. We raised the lack of updated documentation with the registered manager who told us, “We've lost our way a bit, but I do still feel the residents are safe and being cared for.”

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.

The home worked in partnership with external healthcare services to ensure people’s well-being. People told us staff always helped them access services and attend appointments with them where needed.

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.

The registered manager told us they always took feedback on board. Whilst this was not documented, people and staff said they felt listened to and valued. People were supported to maintain their mental and physical health through support from external health care providers and the on-site staff. One staff member told us, “We can always learn more.” People were treated as individuals and staff understood how to effectively support each person to live a life which was meaningful to them.