Archived: Avon Lodge and Avon Lodge Annex

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

We identified a continued breach of the legal regulations in relation to good governance. We found the provider’s oversight of the actions taken to improve the service had not been sufficient or effective, and many issues identified at the previous inspection had not been resolved. Further issues had been identified at this inspection in respect of the failure to adhere to the ‘Right support, right care, right culture’ guidance.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff spoke positively about the visions of the service. One staff member told us, "One thing I will say is that the manager made it clear that a high standard of care must be provided to [people] and the manager said if anyone is falling below that, they cannot work here and will have to leave." Another staff member told us, "The best thing is that at the minute, we have got a leader with a vision and high standard."

The provider had in place a Statement of Purpose which clearly set out its visions and values. Visions and values were discussed and reviewed in staff meetings, supervisions and appraisals. However, this had not been effective in creating a culture whereby staff fully understood people's needs and the importance of supporting people in line with the 'Right support, right care, right culture' guidance.

Staff and leaders had not identified the continued and ongoing shortfalls within the service.

Processes in place had not been sufficient to drive the required improvements and to address the shortfalls identified at the previous inspection. Leaders had failed to demonstrate that they had the required skills, knowledge and competence to improve the service and provide good quality care and support to the people using the service.

Staff told us they felt supported, felt able to raise concerns, and that any concerns raised would be dealt with. The provider had a Freedom to Speak Up policy in place. People were not always fully supported to speak up. One person's communication needs had not been fully explored and one person was not included in the weekly house meeting and so was not able to use that time to raise concerns.

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.

Staff and leaders had not identified or resolved the risks to people, and the omissions in people's support plans and care provided.

Processes were not in place to support good governance. There were continued concerns despite the previous inspection findings and ongoing enforcement. New systems for provider oversight had been implemented and in place but these had failed to identify the issues we found on inspection. Quality assurance audits had not been effective. Required improvements had not been made.

Staff told us that they liaised with the GP and mental health team, however, there was no evidence of working with dieticians despite this being an area identified for improvement at the previous inspection. Robust information had not been sought from the mental health team as support plans contained limited and inaccurate information.

Required improvements had not been made despite support and recommendations from professionals.

Staff and leaders did not have a good understanding of how to make improvements happen. The approach to improvement was inconsistent and did not robustly include measuring outcomes and impact.

The processes in place had not ensured that learning happened following the previous inspection. Evidence-based practice was not embedded throughout the service.