Avebury House

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 changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 had shared their values statement with people, setting out what they should expect from the service. Staff told us the management team demonstrated the provider’s values in the way they worked. The values and how they were applied was discussed in staff meetings and staff appraisals. The registered manager was new in post but had already spent time with staff to talk about changes to the service and how this impacted staff and people.

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.

The service had a manager who was registered with Care Quality Commission. The service was being managed by both the registered manager and the deputy manager with oversight from an area operations manager. Staff told us the management team were knowledgeable and provided them with the support they needed to do their job well. Staff felt since the changes to management, they were appreciated and listened to. Comments included “I hope [manager] does not leave” and “Since [manager has been here, they have been so supportive of me in my role”. Comments from other staff included, “[The manager] seems very good and [the deputy manager] never hesitates to help with hands on stuff”.

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

The service had speaking up procedures which staff were able to access if they needed. Details were shared with staff during their induction, staff meetings and supervision sessions. Staff told us they knew how to raise any concerns and were confident managers would listen to them and respond. Comments from staff included, “I would raise any issues if I needed to and feel confident [managers] would act on them.”

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 provider had processes for staff to request flexibility in their work patterns, for example to enable staff with caring responsibilities or those with health conditions to remain working. Staff were aware of these processes and told us they felt supported by the management team. The manager told us they tried to accommodate staff requests wherever possible. The service employed some sponsored workers from overseas. Leaders told us about the package available to them as overseas workers. Staff confirmed this by telling us, “My certificate of sponsorship and my travel and arrival to England was all handled so well by the organisation”.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The management team completed a range of audits, surveys and observations of staff practice to monitor the quality and safety of the service. In addition to the checks staff were completing, the provider had a quality team who completed regular quality assessments of the service. These included feedback from people and their relatives, observations of staff practice, and a review of records completed by staff. The service had an improvement plan, which meant the provider was able to demonstrate a commitment to continuous learning and improvement. Actions were tracked and reviewed, helping to ensure identified issues were addressed and improvements sustained in a timely way.

Actions from the audits were assigned to named staff with a timescale for completion. All senior managers in the organisation were able to review these actions to ensure they were completed. These systems demonstrated shortfalls were identified and actions were taken to make improvements where and when needed.

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.

Managers told us they worked in close collaboration with a range of professionals to help make sure people received continuity in their care. Examples included working with an occupational therapist, work with the medical team to review people’s medicines, and working with the local authority social care team to support a person in settling into the home. This work was reflected in people’s support plans. Leaders told us they took on board feedback from relatives, while relatives confirmed this: “I get invited to resident meetings” and “I feel my input shapes how my relative receives care”.

The registered manager was keen to resolve any issues and had invited relatives to meetings to discuss any concerns they may have had.

Further, the registered manager was in the process of developing community links with the canal and river trust so people could enjoy a trip out on a canal boat.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Systems for monitoring standards of support people received were used to identify areas of improvement and ensure lessons were learned when needed. This included regular audits and quality assurance checks. The manager said the provider had support systems which enabled managers to share experiences and learn from each other. The manager told us the service had focused on improving the quality of life for people by ensuring a selection of good food and access to activities to enable people to feel more stimulated.