Avenues South Hampshire Services

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

This service scored 54 (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 and strategy to ensure staff in all areas knew, understood and supported the strategic goals of the service and how their role helped in achieving them.

We found some concerns during our assessment which the provider was not aware of. For example, 1 person receiving their medicine covertly. Although we informed the provider of this information once we were informed by staff, this did not demonstrate the provider had a shared strategy and culture with staff.

The provider told us they were in the process of developing a new five-year strategy, and were working with people and relatives.
 

Not all leaders understood the context in which the provider delivered care, treatment and support.

We received mixed feedback from staff. One staff told us, “I think senior managers could be more visible.” Some staff told us they did not feel supported when relatives disagreed or made demands on staff/the service. The registered manager told us they felt supported by senior leadership. They told us, “They all listen to what we have to say and get involved, I do feel the service managers and staff are listened to.”

The provider told us the senior leadership team completed several audits throughout the year as well as monthly visits to the service sites.

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

Staff told us, “I absolutely feel heard”, and “The manager is the best we’ve had, listens, takes it on board and is proactive.”

The provider also told us they have use of an independent external whistleblowing provider, to ensure staff can raise concerns confidentially.

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 registered manager told us they were visible and supported staff to monitor for discrimination and bullying. They told us, “We have an open-door policy as well for staff. We know our team so we can recognise changes. We ensure we are visible and go into the properties.” Staff also supported this and told us, “The manager is inclusive and gives us opportunities for leadership such as key working, updating information and championing in certain areas.” Another staff told us, “I absolutely love it. We do active support here and involve [people] in everything and see them develop. That’s what is different here.”
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
The provider failed to identify people receiving medicines covertly, or in an alternative method authorised from the prescriber’s guidance. This was identified during the inspection and shared with the provider. However, this clearly demonstrated a lack of oversight and governance of people’s care and treatment within the service.
During our visit to the registered office, we were unable to access all necessary information. Inspectors were told throughout the visit that some information was only kept in people’s homes, and this was therefore inaccessible during the site visit. This information included health action plans, epilepsy care plan and PRN protocols.
Throughout our inspection we found the registered manager was not always able to demonstrate they maintained effective oversight of all supported living locations.
We did not see all incidents and accidents were thoroughly investigated, and safeguarding referrals were not always raised when required. The provider confirmed root cause analyses were not routinely completed. This did not provide assurance a robust system and process was in place to implement an effective learning culture.
The provider was not always able to provide information and assurance around people’s care and risks during the visit to the registered office. Inspectors were told to ask the site manager when the visits were taking place. This included assurances around safely supporting people whilst maintaining sexual safety. Therefore, immediate assurances were not always available.
The provider failed to maintain an accurate record of all medicine administrations. For example, MAR charts were not all available to review at the registered office, including the back of the sheets to identify when medicines were administered as PRN and the outcome of this. MAR charts did not include reasons why PRN medicines were administered to ensure the outcome was monitored for effectiveness and frequency of use.
Managers responsible for supporting individuals were not always aware of specific risks to people, and associated alerts and safety information around specific medicines. The provider did not demonstrate they understood their responsibility and duty with specific medicines and associated risk awareness.
 

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.
Relatives reported mixed feedback about partnership working. One relative said, “The house phone is rubbish, if we text, we never get a reply. Professional companies, [like] wheelchair services never get through to the house.”
The provider did not always have access to information about people following healthcare appointments. This did not demonstrate the provider understood their duty to work directly in partnership with services for safe and effective delivery of care and treatment.
One partner told us the service, “Have very good working relationships with the GP services” and “The managers complete referrals to the Community Learning disability team to support over health difficulties.”
The provider told us the service manager and senior management team work flexibly 24/7 and are contactable via mobile phone and email.
 

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.

We found the provider did not demonstrate how they investigated all incidents to identify potential causes. This meant it was unclear how continuous learning was implemented across the local systems. We also found safeguarding concerns were not always raised following some incidents. This did not demonstrate embedded systems and processes in place to identify, and report concerns to ensure people were protected and learning outcomes were embedded.
We noted the provider completed audits; however, these lacked quality and accuracy due to the concerns identified throughout this inspection. For example, the recent medicines audit confirmed all medicines were within expiry date, yet inspectors found someproducts used as part of people’s medicinal care had expired at least 4 months before the inspection.
Relatives gave mixed feedback about learning and improvement within the service. One person told us, “I do not think the staff are trained. The staff need proper training to engage with [person].” Another relative said, “There are gaps in the training, we do not feel it is always person centred as they do not understand the person.”