Avon View

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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement.

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

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider held regular team meetings and staff had supervisions where their wellbeing was discussed. However, some staff told us they did not always feel supported by the management team. A staff member said, “I am aware that the provider as a company has a phone number to speak to someone, but at work we cannot call managers for support, as there is always a culture of blame.” Another staff member told us, “There is lack of communication which makes the service ineffective to run smoothly.”

In response to concerns we raised about the culture of the service, the provider conducted a staff survey and organised meetings with staff to explore their concerns.

The service had an up-to-date Equality, Diversity and Inclusion policy in place.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

We received mixed feedback from staff regarding the leadership and how accessible the management team was. Some staff told us they felt supported and found the management team approachable. However, some staff we spoke with told us they felt unsupported and found the management team not approachable. Comments included, “There is lack of communication,” “Managers don’t listen to the staff making staff stressed out and exhausted,” and “(Management is) not really approachable.”

Throughout our inspection, the management team was open about the improvements that still needed to be made and was motivated to learn and improve the service.

People did not always feel they could speak up and that their voice would be heard.

Staff told us they knew how to whistle blow, and report concerns to external organisations if necessary but did not always feel like they would be listened to by the management. For example, staff told us they had previously raised concerns relating to staffing levels and felt they were not listened to. A staff member said, “[We need more staff and] we always brought it up in the meetings, but managers didn’t take any notice. Instead of listening to the staff, they put more pressure on.”

The registered manager and provider were aware of their responsibilities and the importance of supporting staff to speak up.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Whilst some staff felt the management team were inclusive, others told us they felt they were discriminated against. Comments included, “Sometimes I feel discriminated against,” and “I don’t feel that my workplace is free from discrimination, and we don’t have equal opportunities.”

Staff confirmed reasonable adjustments were implemented where required.

The service did not always have clear systems of accountability or good governance.

Governance systems in place were not always used effectively to identify shortfalls, and corrective actions were not always taken without delay,. For example, through their audit, the provider had identified cleaning products were accessible to people. However, the provider failed to act and rectify this shortfall. Additionally, while the provider had an audit in place to monitor food safety, they were not using it. In response to our feedback the provider told us they will start using the audit and introduce an additional audit which would be checked by the registered manager.

Services we regulate have a statutory responsibility to notify CQC about certain events that occur in a service. Notifications were being submitted, as required.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.

Staff told us they regularly communicated with health and social care professionals as required to meet people’s needs.

The provider had effective working relationships with health and social care partners and social services. One health and social care professional said, “The service has been very good at being flexible around ward rounds and have named nurses who ensure continuity of care.”

The service 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 registered manager told us about the ways in which they were continually looking to improve the service and the work they have already done. This included reviewing the admissions process and, improving assessment processes. The registered manager had also focused on pressure care for people, to help improve people’s skin integrity.