Avalon Clarence Gardens

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.

This is the first assessment for this registered service. This key question has been rated 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.

Staff demonstrated a shared commitment to providing kind and respectful care. They knew people well and understood their individual needs, preferences, relationships and communication styles. People's dignity, rights and preferences were respected in practice and equality, inclusion and human rights were reflected within support planning and day-to-day care.
The provider's stated values around dignity, respect and person-centred support were reflected in the day-to-day interactions we observed.

The manager told us they aimed to provide the kind of care they would want for their own family.
 

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 were visible, approachable and knowledgeable about the service and the people living there. Staff described feeling supported, listened to and able to raise concerns. Throughout the assessment the manager demonstrated a strong knowledge of the people living at the service. It was evident that the service was providing quality, person-centred care.

Leaders demonstrated a compassionate approach to supporting staff and promoting development. A staff member told us, “The service is very supportive about development opportunities and ability to progress.”

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

Information about how to raise concerns, safeguarding issues and whistleblowing was available and accessible within the service. Staff described feeling able to speak up, raise concerns and seek support from managers when needed.

Staff told us they felt listened to by leaders and were confident concerns would be acted upon. They spoke positively about the support they received from managers and described an open culture where concerns could be discussed.

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.

Staff had equal access to information through a range of communication methods, including staff meetings, noticeboards, communication books and rotas. Staff had access to supervision, training and development opportunities.

Staff described feeling supported, listened to and able to contribute ideas and suggestions. Observations demonstrated positive working relationships between staff and leaders and a culture where staff were encouraged to contribute to the development of the service.
The manager told us the service did not tolerate bullying, harassment, or discrimination and if there were concerns raised these would be dealt with immediately.

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 demonstrated a strong commitment to continuous improvement through an effective quality assurance framework. The manager and quality compliance officer carried out regular audits, any actions identified were collated into a single system providing good oversight for the manager and the provider’s operational manager.
Accidents and incidents were analysed to identify any themes and learning, and these were shared with staff at team meetings.

The provider acted on findings in a timely way, making improvements to people’s safety, health, wellbeing and overall experience.
 

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 service worked collaboratively with families, commissioners and healthcare professionals when planning and reviewing people's care and support. People were supported to access opportunities within their local community, including day services and other community activities.

The manager recognised the importance of working in partnership to improve people’s outcomes and held short break review meetings and quarterly meetings with commissioners and local authorities to discuss people’s needs and any service issues.

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 demonstrated a willingness to learn and improve following incidents, audits, inspections and external feedback. Lessons learned were communicated to staff through meetings, supervision, policies and internal communication systems.

Leaders demonstrated an open and transparent approach when discussing the service and were responsive to our feedback during the assessment.

The provider had systems in place to manage incidents and accidents safely and effectively.
Staff received updates when risks changed and lessons learnt were communicated with the staff team and used to make positive changes.