Avalon Park Care Home

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 17 in relation to good governance. 

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 registered manager had a good understanding of the vision and strategy for the service. They told us this was for people using the service to live the best quality of life and to have a purpose. 

The residents’ handbook outlined the providers vision and strategy. This was to be ‘the provider of the kindest homes in the UK with the kindest and most professional staff.’ 

On the first day of our assessment the area director and the registered manager were open and candid about the culture of the service. They told us it had been difficult for the registered manager but how they had shown great resilience despite some cultural challenges. They told us how they felt the culture was improving but how they were ‘on a journey’. Leaders had introduced or expanded upon initiatives to improve the culture, including team building days and activities based on the importance of staff trusting seniors, prizes for staff on the completion of good work, employee of the month and manager of the month and regular team meetings for each staff group for example catering and care staff.  

Staff had differing views on the culture of the service. The feedback we received was mixed. For example, some were positive; a night shift worker told us, “We have no problems with culture on the night shifts, all the staff work well together” and a day shift worker told us, “The culture is good amongst staff, despite there being lots of changes (to staffing).” In contrast, other staff members told us, “The staff are run down and are feeling it; staff are feeling demoralised by how much work they have to do and how they don’t feel listened to by management.” Some staff felt problems in the home were blamed on them and more senior staff did not take accountability. Others told us the culture was much worse than it had been in the past. 

Leaders understood the context in which they delivered care, treatment and support. The registered manager had recruited to ensure a full senior leadership team was in place to work alongside them. 

Leaders, including the registered manager had the skills, knowledge and experience to lead effectively. The registered manager was engaged in a learning programme called ‘learn, lead and change’ to support the management of the deputy managers who had recently been appointed to their positions.  

Leaders spoke favourably about the registered manager. The turn around manager had nominated the registered manager for a kindness in care award which they won in December 2024. 

We reviewed some positive comments regarding the registered manager from relatives and staff who had noted how ‘Nothing was too much trouble for her (registered manager)’ and regarding the positive impact they had on improving the service. 

The staff provided a mixed response regarding how visible and approachable the registered manager and other senior leaders were. For example, some stated the registered manager was ‘Always visible and Approachable’ and how ‘friendly and accommodating’ the area director was. One member of staff told us how the registered manager and seniors were extremely competent in their roles. In contrast, some felt the registered manager did not consider their opinion and ‘Needed to listen more’. A staff member told us “Staff never finish their shifts on time. I should leave at 8pm and often leave an hour to an hour and 15 minutes later.

When we have told leaders they dismiss us and they say the role is achievable in the time you have.” Furthermore, other staff told us they did not feel the registered manager had an open-door policy. Some of the care staff did not find their immediate leads to be accommodating to their needs and felt there was a divide between management, including seniors and themselves.

The provider had a whistleblowing policy in place which clearly outlined the whistleblowing procedure. 

Staff were aware of the process of raising concerns and almost all of the staff we spoke to told us they felt confident to do so. However, some staff did not feel confident raising issues to their seniors in confidence, as they believed it would be shared with the registered manager. Other staff did not feel comfortable raising concerns with the leadership as they did not believe it would be dealt with effectively. 

The staff were aware of how to escalate any concerns they had if they did not feel confident sharing with leaders. Staff who wanted to speak up could share their concerns via the ‘see, hear, speak up service’ which could be accessed by telephone, email or reporting directly via the provider’s internal systems. 

Staff told us the whistleblowing policy and further information regarding how to speak up was in the seniors’ office and in the staff room.  

Leaders told us employees could access further support through the employee assistance programme.  

The registered manager told us about the importance of staff speaking up and said the local authority had recently delivered a presentation to staff on how to do so. The registered manager told us they had an ‘open door policy.’ 

Relatives were confident they were updated and involved if there was something they needed to know. One relative said, “Staff phone me up if they have made a mistake.” This relative appreciated this approach. 

The provider valued diversity in their workforce.  

Most staff that we spoke to told us leaders treated everyone equally, regardless of protected characteristics. However, some staff told us the registered manager had ‘favourites’ and was promoting friends into senior positions. 

The provider had a flexible working policy and procedure in place. The service could evidence where staff had being provided flexible working patterns and most staff we spoke to said their requests had been facilitated. A staff member said, “I really struggled on my shift, and they changed my shift which gave me better home life balance and time with my family.” 

The registered manager told us they had not come across discrimination within the team and told us they would follow the appropriate human resource processes if there was. They were confident staff managed racism toward staff members from residents well.  

The registered manager had completed sessions with overseas staff to support them with their language and to learn about their religious beliefs and culture to identify ways the service could accommodate their needs better. They had also supported staff with occupational health referrals and made adjustments to their roles, taking into account any disabilities staff had. 

The provider had an equality, diversity and inclusion policy. Staff were trained in equality, diversity and inclusion; 89% of staff had completed their training in January 2025. 

Recruitment processes ensured equal opportunities for applicants. 

We identified areas for improvement in the provider’s quality and assurance systems. The daily walkarounds of the service from the 28 and 31 January whilst we were on site had not identified the majority of the concerns which we had found; these included drinks not being available in lounge areas, sprays and air fresheners located on bedside tables and access to drink thickener, found in 1 of the kitchens located upstairs.  There were also gaps in records such as care plans and weekly weights. Important information was also missing from some people’s care plans.

There had also been a deterioration in the overall rating for the service and new regulatory breaches identified.

This meant there was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding good governance.

The area manager, the regional senior nurse and the regional quality service lead were on site regularly to support the registered manager. The registered manager attended multiple meetings, including weekly manager meetings and meetings facilitated by the area manager. Learning outcomes from other regional services were shared. 

The registered manager facilitated regular staff team meetings/supervisions to share information they had obtained from audits, complaints or incidents. Learning and action points were identified and shared with staff within such forums. 

The provider ensured a data pack was produced for the service. Trends, themes and issues arising from the data pack were identified by management and then shared in monthly meetings with senior carers and heads of each department.

Some of the information within the monthly meeting agenda needed more detail and exploration, for example it was noted ‘all staff are to record accurately on the food and fluid charts to evidence resident’s intake.’ We acknowledge this is documented as a reminder but felt further exploration was required.

Staff told us they worked well in partnership with other organisations such as local doctors and district nurses. 

The registered manager told us there were some historic issues with the relationship between the GP practice and the location, but the service was working on building these professional relationships. For example, the registered manager had arranged weekly meetings with the safeguarding lead from the GP practice who acted as a liaison between the 2 services. The provider also had monthly meetings with the lead district nurse. We saw evidence of the medical practice being appreciative of the registered manager’s approach; they felt the working relationship had ‘greatly improved.’ 

Leaders of the service worked closely with the local authority quality team. The registered manager and area director told us the most recent visit from the team was a positive one and there had been no concerns raised. The service provided placements for health and social care students.   

People who used the service were positive about the quality of care provided. Comments included: 

We saw evidence of the provider responding to suggestions made by residents and staff with the ‘You Said, We Did’ incentive. We saw evidence of clocks being in place now in lounge areas, a lost property file and a trolley being ordered for night staff on which to place towels. This incentive seemed effective but unfortunately, we did not see any further evidence of this being actioned following May 2024. 

The registered manager told us care reviews for residents and their families were completed regularly. We saw evidence of care review forms being completed which allowed residents and relatives to provide feedback on care. The meeting provided updates regarding care and addressed any concerns residents and relatives had regarding care.  

Processes, documented in the governance section, did not always provide sufficient or consistent oversight of some of the key issues within the service. 

Although there were shortfalls, the registered manager had identified areas for improvement such as falls and was working to develop a falls team. Staff within this team would be specially trained and provide support reviewing, assessing and managing falls. 

The registered manager found innovative ways to gather information and feedback on staffs’ understanding of safeguarding processes and completes reviews with staff about residents’ care plans to check their understanding.