- Care home
Avonmere Care Home
Assessment report published 18 November 2025
Contents
Ratings
Our view of the service
Date of on-site assessment: 21, 27 and 28 August 2025. Avonmere Care Home is a care home registered to provide accommodation and personal care. The service provides care and support for up to 76 older people. At the time of the assessment there were 70 people using the service. At our last assessment, published September 2023, the service was rated requires improvement. The provider was in breach of the legal regulation in relation to safe care and treatment. We carried out this assessment to review actions taken by the provider following our last assessment. During this assessment we found improvements and the provider was no longer in breach of this regulation. We assessed 15 quality statements in safe and well led. At this assessment, the overall rating was good. The rating for the safe key question has changed to good. At this assessment we found the provider was in breach of the legal regulation relating to good governance. The rating for the well led key question remains as requires improvement. The ratings for the quality statements we did not assess remain unchanged. Some improvements had been made particularly relating to medicines management since the last assessment; although further work was required to ensure people’s individual and environmental risks were consistently assessed. The provider’s governance systems were not always effective in monitoring and improving the quality of the service in relation to individual and environmental risks. Provider oversight was insufficient to effectively monitor and address the shortfalls identified. Our observations of the care provided were positive and overall people and their relatives told us they were satisfied with the service. Medicines were managed safely, and health professionals told us they had good communication and positive working relationships with the service. Staff spoke positively of their work and felt supported by the management team. The provider was responsive to shortfalls identified and committed to making improvements. We asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
We spoke with 14 people who used the service and 17 relatives about their experience of the care provided. Some people could not directly tell us about their experiences, which meant we spent time observing interactions with staff. We used the Short Observational Framework for Inspection (SOFI), a structured observation tool to help us understand their experience and assess whether they received good care. We observed a calm and supportive environment, where people were supported to move about the service independently. Areas of the service were decorated to enhance the experience of people living with dementia. We observed positive interactions between staff and people. Staff demonstrated an understanding of people’s needs. People and their relatives found staff to be kind, caring, respectful and people enjoyed living in the home. People said they felt safe and well supported. Feedback from 1 person included, “I feel safe – there is always someone there at night”. Relatives were assured about the care people received. A relative said, “I think that it is excellent – first class, it is marvellous, all the carers are very very good.” While most people and relatives expressed general satisfaction with their care they received, our assessment found some elements of care did not meet the expected standards.