Averley Home

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• 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 service under the new provider. This key question has been rated 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 provider was in breach of the legal regulation relating to good governance.

This service scored 61 (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.

Staff understood the aims of the service were to support people with a learning disability and autism to go out in the community and lead active lives. They said the service was a positive place to work as there was good communication between team members and support from the deputy and manager. Staff said they thought they had received the training they needed for their role, but that some of it may have taken place a while ago. Formal staff supervisions, which can be used to highlight staff training and development needs, were not in place at the time of the assessment. As a result, not all staff had received essential training.

Relatives described the service as having a friendly atmosphere and that staff were always welcoming.

The provider had compassionate leaders who had the skills, knowledge, experience and credibility to lead effectively.

Relatives were overwhelmingly positive about the deputy and registered manager. They described them as being very understanding and personable. One relative commented about the registered manager, “She is really lovely and dedicated. She is particularly good at understanding what makes people tick. She is very approachable.” We observed the registered manager knew people well and was well liked by the people who lived at the service.

We observed people smiling when they were communicating with the registered manager. When speaking about the people that lived at the service the registered manager demonstrated they had a genuine affection for people. Staff were also positive about the support and leadership of the management team.

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

Staff felt able to voice their views with a member of the management team at any time. They said a member of the team was always available to speak to and listened and acted on any concerns they may have. Relatives also felt able to contact the management team and had always found communication good and felt they were listened to.

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 spoke positively about their experiences at work and told us they were treated fairly. The provider was aware of their responsibilities in relation to the Equality Act 2010. Staff told us they were asked if they required any reasonable adjustments which were then put into practice. Staff described the registered manager as, ‘Flexible’. Several staff said they had been able to change their working pattern and hours to fit around other responsibilities. Training in equality and diversity was provided to all staff.

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 had been responsible for the service for a year, since registering on 30 April 2025. They had not undertaken a review of existing systems to assess if they were effective in ensuring the governance of the service. During the assessment we found the provider had a range of procedures to monitor the quality of the service but had yet to put them all into practice. For example, it was only when we asked about any lessons learned from accidents and incidents, that the providers lessons learned evaluation tool was completed.

The provider’s auditing processes had not identified concerns we found at this assessment. These included shortfalls in the management of medicines and staff training and competence. As a result, staff had not been sufficiently trained or their competence assessed to support people with their specialist health needs, which put them at potential risk of harm.

The provider was reactive in making necessary changes to the service. We identified there was no structured sign off process to ensure new staff were competent. There was also an absence of formal channels for staff views to be feedback, such as team meetings, staff supervisions and staff surveys. A probation competence check and staff supervisions were only put into place once their omission had been brought to the providers attention.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. The provider had appropriately informed us of events and incidents.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners but there were some delays in ensuring improvements.

The service had partnerships with social and health care professionals to ensure good, joined up care for people. However, we received feedback that there had been delays in some people receiving the equipment they needed. They told us that this was because the provider had not acted in a timely manner to purchase equipment for people when they had recommended it, to improve their quality of life.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The provider had not effectively used their own auditing processes and procedures as the basis for making service improvements. As a result, there were shortfalls in the service that they were not aware of until they were brought to their attention by the local authority, and also during this assessment.

The registered manager was receptive to the feedback we gave after the assessment. They took immediate action to address areas of risk where they were able, to minimise the impact to people’s safety. The registered manager took other steps such as adding proposed dates to schedules of works and initiating processes but there has been insufficient time during this inspection to assess if they have ensured the necessary improvements.