Avon Lee Lodge

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 there were shortfalls in service leadership, specifically around the governance processes and systems used. The provider did not always have effective governance systems in place to monitor and improve the quality and safety of the service.

The service was in breach of legal regulation in relation to governance. Systems were either not in place or were not operating effectively as they had not identified the shortfalls found at this inspection.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not always have clear responsibilities, roles, systems of accountability and good governance. Audit processes were not always effective and had not highlighted the shortfalls we identified during the inspection. Governance, management and accountability arrangements were not always in place, or effective. Some audits were incomplete and lacked detail. This meant assurances could not be provided regarding effective oversight of the service.

We identified there was not an “as required” (PRN) protocol process in place. When people were prescribed additional medicines on a PRN basis, there was not sufficient guidance for staff on what steps to take regarding the PRN medicine. One person was prescribed covert medicines; however the relevant Best Interests process had not been completed. Some people’s medicine records held conflicting information, such as incorrect room numbers or conflicting dietary information and had not been kept up to date. Regular medicine audits were carried out, however there was no action plan to rectify shortfalls and none of the shortfalls we had identified during the inspection had been highlighted by the provider’s audit.

Action plans in relation to the environment of the home had been put in place to drive improvement by the provider, however some of these were not completed or up to date. There was not a clear system in place to show an analysis, review and identification of lessons learned from accidents and incidents had been regularly completed. This meant people were at a risk of avoidable harm as the provider did not have a structured governance process in place which would provide a consistent lessons learned approach.

There was not a system in place to identify the shortfalls we highlighted in relation to the Mental Capacity Act 2005 (MCA). This meant the providers governance processes did not fully protect people’s rights in accordance with MCA.

We discussed our findings with the registered manager who started to take action during the inspection to address the shortfalls identified. For example, implementing a new system for reviewing themes and trends of incidents and accidents within the service.

People and relatives told us they had confidence in the management team and staff. A visiting health professional told us, “It’s a welcoming environment, the staff are knowledgeable and it’s a calm atmosphere. People are always happy to see staff. They are well looked after and the provider will always flag up any concerns. The management are supportive and responsive and support families well too. They know the people here very well. I get a snapshot of each person, they tell me the slightest changes with them, it is so good, that is so important.”

Staff felt well supported by the management team and told us they really enjoyed their roles and loved working at Avon Lee Lodge.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.