Avenues South East - 87 Westbrook 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 75 (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.

There was a clear and positive culture at the service which focused on people’s rights and delivering a high quality of care. Guidance in place clearly set out the barriers people may face in society and how staff would support them to combat these. For example, one person faced challenges in sharing space or equipment and staff had strategies in place to help this person doe so in a safe way. This was an example of how the provider and staff were helping people learn important life skills to support them in living empowered and independent lives.

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.

Leaders led by example and role modelled the values they expected of their team. Management were knowledgeable both about people’s needs, and about best practice guidance for supporting individuals with a learning disability and autistic people. The manager told us “Our role is to ensure people have a positive quality of life by enabling them and have control over what they want to do. We do everything we can to promote choice and people can spend their day as they wish”. Staff and families told us leaders were accessible and acted with openness and integrity at all times. One relative explained “If anything happens to my relative, they will always let us know and keep us updated”.

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

There was a positive culture at the service where staff felt confident that where they raised concerns, they would be listened to and could share these openly and with confidence. There were regular team meetings which discussed each service user and gave staff and opportunity to share their observations or concerns in a collaborative manner. However, staff told us management were always available and listened to them. One staff member told us “I do feel comfortable in approaching the assistant manager or registered manager. We have regular supervisions but there are lots of opportunities to check in or speak to them”. There was a whistleblowing process which staff were knowledgeable about how to follow, as well how to raise concerns with other agencies such as the local authority or CQC.

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.

All staff had received training around equality and diversity, and told us they were treated with kindness and respect by management and colleagues. If people required additional adjustments to be made to allow them to work safely or reflect people’s personal circumstances then these were put in place. Staff felt their wellbeing was supported at all times. One staff member told us “I really enjoy working with the registered manager and my job. We have an agreement that allows me to have a work life balance. I feel pushed and challenged, but also able to look out for the wellbeing of my team”.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were robust governance process in place to ensure the delivery of high quality care. This included regular checks on people’s care plans and risk assessments, and around staffing levels and knowledge to ensure care was being delivered safely. Audits were undertaken both by the registered manager and area manager to monitor the quality of care, which were effective in identifying areas for improvement. There was a clear action plan setting out how areas for improvement would be addressed including timescales for when these would be achieved. The service had a detailed business continuity plan setting out arrangements for how staff should ensure the safety of people, for example, during an emergency such as loss of a utility or significant weather event. The governance processes ensured leaders had an accurate picture of risk, and resulted in a service where people and staff felt supported and empowered.

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.

There were strong and collaborative relationships with stakeholder organisations, with clear guidance setting out when staff may need to make a referral to another health and care organisation to safely manage people’s needs. One visiting professional told us “…Staff members engaged with me around how my recommendations could be put into practice. They participated well and appeared keen to implement these techniques to support the client”. Staff also worked with their wider community including forming relationships with voluntary groups to support people in accessing opportunities to improve their quality of life. This included forming social connections, or local leisure services such as swimming pools where they worked to put in place a safe plan to support people participate in swimming safely.

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.

Regular opportunities for learning were actively sought, and areas for improvement were identified and embedded through a system of regular audits and checks. There were robust systems to analysis incidents and people’s outcomes, which were used to identify any unmet support needs or where changes needed to be made to their care. Staff were actively involved in opportunities for learning including team meetings, debriefs and key working. However, there was also organisational learning shared with management through attending regular meetings to share learning and social updates from other services. The service also engaged with other local services to share ideas and challenges, including engaging with regional care provider representative groups. One staff member told us “I feel empowered to improve. I enjoy having a hands on role in the care I provide, and being able to review and update people’s documentation in response to their changing needs. We learn together”.