Avon Lee Lodge

The following is CQC's published account of its assessment, published 23 June 2025. References to “we” mean CQC. It describes findings at that time.

Date of inspection: 20 March to 25 March 2025. Avon Lee Lodge is registered to provide care and support for up to 30 people. At the time of this inspection, there were 24 people living at the service. Our inspection was prompted by concerns we had received regarding medicine management processes. Following the inspection, we were assured by the processes in place to keep people safe. Risks to people’s health and well-being were assessed and managed well. Staff spoke knowledgably regarding safeguarding procedures and there were appropriate levels of staff employed on each shift to ensure people were cared for safely. People received continuity of care from a consistent team of care staff that knew people well. There was a programme of premises maintenance and infection prevention and control processes in place to ensure the environment and people remained safe. Medicines were ordered, stored and administered safely. Staff felt well supported in their roles and thoroughly enjoyed their job. People, relatives and health professionals all spoke highly of the management team and care staff, who worked well together as a team to ensure people received individual person-centred care and support.

However, we found 1 breach of the legal regulation in relation to good governance. The provider did not always have effective governance systems in place to monitor and improve the quality and safety of the service. Governance processes were not always effective and did not support the provider or registered manager to maintain oversight of the service. There were shortfalls identified in relation to consent to care and treatment and governance systems were either not in place or operating effectively. The provider’s processes for assessing people in accordance with the Mental Capacity Act 2005 were not always robust. Audits were in place but they had not identified the shortfalls identified during this inspection.

We have asked the provider for an action plan in response to the concerns found at this inspection.