Avonmere 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 requires improvement. At this assessment the rating has remained the same. 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 governance at the service.

This service scored 62 (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. The provider recognised the importance of maintaining a positive culture where everyone is included in decision making processes. At the time of the assessment, the provider told us they were reviewing company values to strengthen a shared vision for the service. Recent away days had been held to review communication styles within the management team. Staff and leaders reported feeling supported, demonstrated a positive approach to the service, and respected the human rights and diverse needs of both people and staff. One staff member said, “They are an excellent organisation to work for. They genuinely care for the staff and the residents."

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. Most people were happy with the way the service was run by the provider. They said, “I have spoken to the Manager, we have had no issues or concerns. [Staff] in the office is very good and [Deputy Manager] is exceptional, and very helpful” and “if I need anything I would speak to the Manager, I have no concerns I am kept informed by emails and phone calls.”

The provider said they considered the impact on staff if someone they cared for had died. They said they encouraged staff to come into the office for a de-brief. Staff told us they felt supported when they lost 2 colleagues recently. Staff were positively supported by the management team to carry out their job. For example, 1 said, “I feel appreciated, they thank us during team meetings, they buy us pizza and takeaways as a thank you”. They said they felt included and treated fairly. Whilst we found leaders at all levels were visible within the service and they led by example; we found they had not always identified issues we found during this assessment.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had made significant improvements to ensure people and staff could speak up and be heard. The manager and deputy manager had worked to develop the organisational culture and to make sure people felt confident when concerns were raised, they were listened to and addressed. Systems enabled staff to raise concerns through supervisions, staff meetings, surveys and communication with office staff. A staff member said, “They are approachable, I can suggest things and I know I am listened to especially if I report a change in a person’s condition, they will call the GP.” Leaders acted in an open and transparent way. When something had gone wrong this was acknowledged and an apology made where appropriate.

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. The management team informed us they respected people’s different religious and cultural beliefs. There was a strong ethos at the service of treating people as individuals, this extended to the workforce as well. Staff told us they were excited the management team were arranging a room which all staff could use for prayers or quiet reflection according to their religious or social needs.

Staff felt they were treated as individuals and their needs were taken into consideration, such as shift times being arranged to fit in with studying and family commitments. There was an open and inclusive recruitment procedure. The management team described how they recruited staff based on their compassionate natures, skills and experience. Care staff were positive about working at Avonmere Care Home and would recommend it as a place to work.

The service did not always have clear and effective governance, management and accountability systems. They did not always act on the best information about risk or share this securely with others when appropriate. Audits completed at service level did not identify or address shortfalls found during this assessment. For example, audits of care plans were not effective in identifying and addressing the shortfalls we found with people’s risk assessments. Audits did not address shortfalls related to the emergency grab bag. We found processes in place to audit risk assessments required further development to ensure they were sufficiently robust. While the provider was present and responsive during the assessment, providing evidence of actions taken to address shortfalls. We found provider oversight was insufficient to effectively check and monitor areas where issues had been identified. Governance processes had led to some improvements in addressing individual risks since the previous assessment. The provider told us they had identified governance as an area for improvement and had plans to implement a robust audits and checks.

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 management team told us how they worked in partnership with professionals such as the GP, local authority, and the community mental health team to meet people’s individual needs. Following the last assessment, the service had worked with the speech and language therapy team to improve risk management for people with swallowing difficulties who required a texture modified diet. People and their relatives confirmed the GP carried out regular visits to the service and people had access to health appointments when needed. Health professionals who worked with the service told us there was good communication between the management team and external agencies.

The service had not always focused on continuous learning, innovation and improvement in the service. At the last assessment, some risks were not adequately documented in care records which meant there was a lack of clear guidance for staff to follow to manage risks. At this assessment, whilst some improvements had been made, we found examples where some individual and environmental risks had not been sufficiently assessed and mitigated. We noted this issue had been raised at the last assessment but had not yet been fully addressed. The provider had processes to involve and gather feedback from people, their relatives and staff. These included meetings and surveys. Whilst relatives told us they felt able to approach staff as needed, the majority told us they had not been asked for formal feedback. Whilst feedback was positive, analysis of surveys completed for relatives and staff showed a low response rate. The provider told us they had established several ways to encourage relatives to share their views—such as coffee mornings, relative meetings, and care reviews. The management team was committed to providing a good service and responded promptly to shortfalls identified during the assessment. The provider was keen to promote ongoing service development and improvement and shared their plans to improve the consistency and quality of care records, governance and IT systems.