Last updated: 10 February 2026
"Stable staff team and supportive culture, but medicines management shortfalls and weak governance oversight need improvement."
The service had not always ensured that medicines were managed safely. Shortfalls included the completion of MAR and “medicine as required” processes. There was not an “as required” (PRN) protocol process in place.
Staff felt well supported in their roles and thoroughly enjoyed their job. Staff are happy in their roles. We are listened to; we are a good team.
There were adequate numbers of staff available on each shift to ensure people were cared for safely. There was a stable staff team with some staff having worked at Avon Lee Lodge for many years.
Staff received mandatory training through a mixture of practical face to face training and on-line courses. We constantly do training, all the mandatory courses.
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.
Not covered in this targeted medicines and safety inspection report.
Medication safety has gaps like no guidance for as-needed drugs and audits missing problems.
There was not an “as required” (PRN) protocol process in place, or guidance for staff on what steps to take regarding PRN medicine.
Managers checks are not strong enough and missed issues like mental capacity paperwork and accident reviews.
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.
Only standard mandatory training with no specialist courses or funded qualifications mentioned.
Staff received mandatory training through a mixture of practical face to face training and on-line courses.
AI Generated
Last inspected: June 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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