Avon Reach

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 outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 93 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

Leaders had created a highly positive, inclusive and supportive culture characterised by openness, accountability and a shared commitment to achieving the best possible outcomes for people. Leaders were highly visible and approachable throughout the inspection and consistently demonstrated the provider's values through their interactions with people, relatives and staff. Their leadership provided a clear example for others and helped ensure expectations remained focused on delivering person-centred care and improving people's lives. The strength of this culture was reflected both in external recognition and in the outcomes achieved for people. The service was recognised as a Care Awards winner in 2025 and examples reviewed during the assessment demonstrated a culture where staff routinely sought opportunities to improve people's lives rather than simply meet their care needs. Staff were encouraged to challenge barriers, explore possibilities and focus on what people could achieve, resulting in exceptional outcomes relating to independence, wellbeing, inclusion and quality of life.

People's experiences reflected the positive culture established by leaders. Throughout the inspection, people consistently described the home as an exceptional place to live where they felt respected, listened to and valued. Feedback indicated staff knew people well, treated them with kindness and dignity and provided reassurance when needed. This demonstrated the provider's values were not simply statements of intent but were evident in people's everyday experiences of care and support.

Staff consistently demonstrated a strong understanding of the provider's vision and values and described a culture where people worked together to achieve shared goals. One staff member described a "very happy team working together toward the same goals and vision with appropriate systems and processes to help us get there." Another said, "The culture is very good. The team is very friendly, helpful and understanding. We all get along so well because we truly are working to achieve the same things: Good quality care for our residents and a happy home." These comments demonstrated staff understood the service's purpose, felt part of a shared vision and were motivated to deliver positive outcomes for people.

Relatives also spoke positively about the culture within the home and the quality of care provided. A relative told us, "It's a good place, best decision we made." Feedback from relatives consistently reflected confidence in the leadership, staff team and values of the service. This demonstrated the provider had established a culture which was recognised and valued by people, relatives, staff and external stakeholders alike.

The provider's culture was reflected not only in people's experiences but in the consistently exceptional outcomes achieved across the service. Examples reviewed during the assessment demonstrated staff were empowered to challenge assumptions about ageing, disability and risk, supporting people to fulfil lifelong ambitions, regain independence, maintain community connections and continue participating in activities that gave their lives meaning. Staff consistently described feeling trusted to develop ideas, lead initiatives and find creative solutions to barriers people faced. This culture had created an environment where innovation, positive risk-taking and person-centred thinking were embedded in everyday practice rather than being limited to management-led projects. As a result, people achieved outcomes including fulfilling lifelong ambitions, maintaining valued community roles, regaining independence and continuing activities that reflected their identities and aspirations, despite increasing age, frailty or complexity of need.

The provider had exceptionally 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 and did so with integrity, openness and honesty.

Leaders demonstrated a strong commitment to continuous learning and improvement and used this to create a culture where staff at all levels were empowered to lead and innovate. Following leadership development and structured self-reflection, the registered manager recognised the importance of moving from a predominantly hands-on leadership style to a style which actively enabled others to develop confidence, take ownership and contribute ideas. Leaders created opportunities for staff to lead projects, solve problems and develop solutions that enhanced people's experiences. This resulted in a culture where innovation and improvement were embedded throughout the workforce rather than driven solely by management.

The impact of this approach was evident across the service. Staff demonstrated confidence to take ownership of initiatives that delivered meaningful outcomes for people. Examples included supporting a 96-year-old resident to fulfil a lifelong ambition of flying an aircraft, enabling another resident to safely return to playing table tennis through positive risk-taking, developing personalised programmes that helped people maintain independence, introducing innovative infection prevention measures and working proactively with specialist professionals to support people with changing needs. These improvements were led by staff from across different teams rather than being dependent on management direction alone. This demonstrated leaders had successfully created an empowered workforce focused on achieving outstanding outcomes for people.

Leaders also actively sought opportunities to strengthen people's lives through community partnerships, innovation and learning. The service developed relationships with local organisations, including community groups, arts organisations and intergenerational projects, creating additional opportunities for social engagement and community participation. The registered manager encouraged staff to test new ideas, evaluate their effectiveness and share learning across the service. This resulted in initiatives which enhanced people's wellbeing, increased opportunities for participation and strengthened links with the local community. This demonstrated leaders were not content with maintaining existing standards but continually sought ways to improve people's experiences and quality of life.

Staff consistently praised leaders for their knowledge, approachability and willingness to support others. One staff member told us, "The management is approachable, realistic and willing to be a worker. Hands on," whilst another said, "Management has been brilliant, very supportive." Staff feedback consistently reflected a culture where people felt trusted, valued and encouraged to contribute ideas. This demonstrated leaders had earned the confidence and respect of the workforce through their integrity, visibility and support.

People and relatives also spoke positively about the leadership of the service. A person told us, "The management here is friendly and kind," whilst a relative commented, "I've spoken with [Manager] from time to time, she's always helpful." Another relative described how the registered manager had personally supported their family member to go for a walk along the harbour because they enjoyed watching the boats. These examples demonstrated leaders remained connected to what mattered to people and had created a culture where staff and leaders alike were encouraged to go beyond traditional expectations in order to improve people's lives. The numerous examples of innovation, positive risk-taking and personalised support reviewed during the inspection provided evidence of leadership that had translated directly into improved experiences, opportunities and outcomes for people living at the service.

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

The provider had established a culture where staff were encouraged and supported to raise concerns, share feedback and discuss their wellbeing. Staff told us they had opportunities to speak openly with leaders through day-to-day discussions, team meetings, supervisions and annual staff surveys. Records demonstrated concerns raised by staff were investigated appropriately and feedback was used to drive improvements, including increased wellbeing support and additional learning and development opportunities. This demonstrated leaders listened to staff and took action in response to feedback.

The provider had appropriate arrangements in place to support staff to raise concerns both within and outside the service. A whistleblowing policy was in place, reflected current guidance and was clearly available to staff. Speak Up information was displayed throughout the service and staff demonstrated a clear understanding of how concerns could be escalated if required. One member of staff told us, "I am confident to go speak up to someone if I have any issues." This demonstrated the provider had created a culture where staff felt heard, valued and confident their concerns would be taken seriously.

The provider strongly valued diversity within its workforce and actively worked towards an inclusive and equitable culture. Leaders demonstrated a clear commitment to ensuring staff from different backgrounds, cultures, faiths and experiences felt respected, valued and supported to succeed.

Equality, diversity and inclusion were embedded within the culture and day-to-day practice of the service. Policies reflected current good practice and staff described a workplace where differences were respected and inclusion was actively promoted. Leaders demonstrated a commitment to creating an environment where staff felt able to be themselves, contribute fully and be treated with fairness and dignity. This demonstrated an inclusive culture where diversity was recognised as a strength.

The provider took practical steps to remove barriers and promote equality of opportunity. Records evidenced reasonable adjustments were made where required, and staff were supported through flexible and personalised working arrangements that enabled them to balance professional responsibilities with personal, cultural and religious commitments. One staff member told us, "I am Muslim and I have been really supported to get shorter shifts during Ramadan." Staff also described a workplace where opportunities for development and progression were available regardless of background or personal circumstances. Leaders created opportunities for staff from different backgrounds to succeed, helping people feel valued, supported and able to contribute fully to the service. This demonstrated a genuine commitment to inclusion that extended beyond policy into everyday practice.

Staff consistently described a positive and inclusive workplace culture. One staff member told us, "We accept each other and we are like family really." Feedback reflected a culture where differences were respected, people felt comfortable being themselves and colleagues supported 1 another. This promoted positive staff wellbeing, engagement and retention and helped create a workforce that felt valued and empowered.

The provider actively celebrated diversity and promoted cultural understanding across the home. For example, 1 member of staff delivered a presentation to people and colleagues about their home country, sharing information about its culture, history and places of interest. People responded positively and valued the opportunity to learn more about another culture from a personal perspective. This demonstrated the service went beyond meeting equality requirements by promoting inclusion, encouraging meaningful cultural exchange and fostering mutual respect between people and staff.

Overall, leaders had created a culture of belonging where staff from different backgrounds felt respected, supported and able to succeed. This meant people were supported by a diverse, inclusive and valued workforce whose different experiences, perspectives and skills contributed positively to the quality of care provided.

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.

The provider had established governance systems which supported effective oversight of quality, safety and performance across the service. Audits, quality assurance processes and management oversight were used to monitor care delivery, identify areas for improvement and drive ongoing development. Where issues were identified, action plans were developed with clear responsibilities and timescales, and leaders monitored progress through a comprehensive service improvement plan. This demonstrated a structured approach to governance that supported continuous improvement and the delivery of safe care.

Leaders had systems in place to monitor risk, respond to incidents and ensure appropriate information was shared with relevant organisations. Records demonstrated the service notified partner agencies appropriately following accidents, incidents and safeguarding concerns. A business continuity plan detailed arrangements for a range of emergency situations, helping to support service resilience and continuity of care. This reduced the risk of disruption to people's care and ensured important information was acted upon promptly.

Staff consistently expressed confidence in the leadership and governance of the service. A member of staff told us, "Any problems they solve it straight away and we feel valued not just a number." Feedback reflected a culture where leaders were visible, accountable and focused on maintaining high standards of care. This demonstrated governance arrangements were understood by staff and supported the delivery of good quality, sustainable care for people.

The provider clearly understood and carried out their duty to collaborate and work in partnership. Strong relationships with community groups, charities, volunteers and local organisations helped ensure people remained connected to their community and were supported to make meaningful contributions to it.

The service had developed a wide range of community partnerships which enriched people's lives and created opportunities for social inclusion, participation and engagement. These partnerships were embedded within everyday life and reflected the provider's commitment to ensuring people remained active members of their local community rather than becoming isolated from it following admission to the service.

The provider actively created opportunities for people and their local community to build meaningful and lasting relationships. Weekly community coffee mornings had been established for more than three years and brought together people living at the service and members of the local community. During the inspection, we observed community members participating in activities and engaging naturally with people. One person told us, "[Home] is part of the community and the community is part of this home." The service also worked in partnership with an intergenerational storytelling charity, enabling babies and toddlers to visit the home regularly. People spoke warmly about these visits and described how they enjoyed watching the children grow and developing ongoing relationships with them. This demonstrated community partnerships were not one-off events but had become a valued and meaningful part of people's lives.

The provider also supported people to contribute positively to their local community. People living at the service were actively involved in charitable initiatives, including preparing donations and seasonal gifts for families supported by the local food bank. The service worked closely with local faith groups and community organisations, and people participated in fundraising activities to support causes important to them. For example, following significant fire damage to a local church, people and staff worked together to support local fundraising efforts. This demonstrated people were not only supported by their local community but were enabled to continue making meaningful contributions to it.

The service demonstrated a strong commitment to ensuring people remained connected to community life, culture and local events. People participated in community celebrations including local Christmas and Carnival events and were actively involved in planning and preparing for these activities. Volunteers also visited regularly to provide companionship and develop meaningful relationships with people. These partnerships helped reduce social isolation, strengthened people's sense of belonging and enabled them to remain active participants in the communities that mattered to them. This demonstrated a culture where partnership working was used to enhance people's quality of life, strengthen community connections and create opportunities that might otherwise not have been possible.

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.

A culture of continuous learning, innovation and improvement was embedded throughout the service. Leaders actively encouraged staff to develop their knowledge, share learning and explore new approaches to improving care and support. Staff participated in external training, qualifications and development opportunities, and learning was routinely shared across the workforce. For example, 1 member of staff was working in partnership with Havant and South Downs College to develop bespoke Level 2 training for companions, with the longer-term aim of expanding opportunities across the provider's wider services. This investment in learning and development was reflected in the confidence staff demonstrated when leading initiatives, developing new ideas and delivering personalised support designed around people's goals and aspirations.

Leaders actively sought opportunities to enhance practice through collaboration with educational organisations and external specialists. A notable example of this was the service's partnership with physiotherapy students undertaking supervised placements within the home. Students worked alongside qualified professionals, people and staff to review mobility support, rehabilitation approaches and falls prevention strategies. At the end of placements, findings and recommendations were formally shared with staff and incorporated into practice. Learning from this project contributed to improved mobility outcomes and reductions in falls for several people. For example, 1 person admitted to the home at end of life significantly improved their mobility through a structured rehabilitation programme, increasing their walking distance from approximately 15 metres to 200 metres and regaining independence to attend meals, activities and outings with friends and family. This demonstrated how learning was actively translated into measurable improvements in people's wellbeing and quality of life.

The service also embraced innovative approaches to supporting people's wellbeing. Rather than relying solely on externally delivered activities, leaders invested in developing the skills of their own workforce so staff could use creative movement and music techniques as part of everyday support. Staff described how these approaches enabled people living with dementia to participate at their own level, including those who found traditional group activities difficult. One relative told us it was "lovely to see [Person] joining in with activities, especially movement and music", adding that staff helped keep their family member "happy and content". Because staff throughout the home had developed these skills, support could be adapted for people who chose not to attend group activities, helping ensure more people benefited from meaningful engagement and stimulation.

Innovation and improvement extended beyond learning initiatives and were evident throughout the service. Leaders actively sought opportunities to challenge traditional approaches and explore new ways of improving people's experiences. Examples included the introduction of an innovative cleaning system which reduced people's exposure to chemical cleaning products whilst maintaining effective infection prevention standards, partnership working with specialist continence professionals to develop solutions that enabled a person with complex needs to remain living in the home and seeking specialist Admiral Nurse expertise to support assessment and decision-making for people living with advancing dementia. These examples demonstrated a culture where staff and leaders continually looked for better ways of supporting people and welcomed external expertise to strengthen outcomes.

Staff consistently described a culture where learning was valued and improvement was encouraged. Staff told us the provider was highly supportive of career progression and actively created opportunities for people to develop new skills and knowledge. Learning was routinely discussed, shared and incorporated into day-to-day practice, ensuring improvements benefited both staff and people living at the service. The examples reviewed during the inspection demonstrated learning, innovation and improvement were not isolated projects but were embedded throughout the culture of the service and consistently resulted in improved independence, wellbeing, safety and quality of life for people.