Ashurst

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 inspection 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 71 (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.

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 provider ensured there was always suitable cover at the service. This included leaders and professionals being on-call throughout the night.

Leaders of the service were suitably experienced and qualified and had clearly defined roles and accountabilities. The leaders had both worked previously in the social care sector and so had the skills and competence to get involved in the direct delivery of care if required.

Leaders were knowledgeable about issues and priorities for the service. They had access to appropriate support, including staff support groups and individual line management. Leaders had the opportunity to develop within their roles.

Leaders took full responsibility within their roles and challenged poor performance when necessary.

Staff told us leaders were accessible, visible and approachable to them and the people being supported. One staff member said, “Leaders are very knowledgeable and approachable and are always visible”, whilst another staff member said “They (leaders) are really knowledgeable and are easy to open up to.” The registered manager explained how they had an ‘open-door day’ each month in which staff and people could speak with them and voice any concerns.

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

The provider ensured there were clear procedures and policies which staff could follow if they needed to raise concerns.

Staff and leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns and promoted the value of doing so. We saw information leaflets within the service which outlined the procedure for highlighting concerns.

Staff knew how to raise concerns and access support and felt leaders would listen and respond effectively. Staff consistently told us they felt able to discuss their concerns, views and ideas with the registered manager.

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 a diversity and inclusion statement which outlined the importance of celebrating difference and a commitment to equal employment opportunities regardless of protected characteristics.

The provider ensured job applicants were anonymised by the onboarding system prior to shortlisting to ensure fairness.

Policies and procedures incorporated all aspects of recruitment and staffing and included retention plans, equality, diversity, fairness and protected characteristics.

Support and reasonable adjustments were made for staff as and when needed. The registered manager told us some adjustments had been made for staff with dyslexia and dyspraxia whilst a staff member explained how the provider had allowed them to work flexibly to support them with responsibilities they had in their personal life.

Staff had completed equality, diversity and inclusion training. All staff we spoke to told us they were treated with fairness, respect and all staff were treated equally by leaders.

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.

Staff were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

The provider operated effective governance processes. The provider had a clinical audit system which ensured staff were undertaking regular clinical audits, and analysis of recorded incident and accident data was in place to provide trend analysis and lessons learned. We found that clear systems of recording and handover of risk supported staff at all levels to work with people.

Managers and staff were clear on the risks they faced and worked hard to make improvements and mitigate any risks. Performance and risks were routinely discussed in staff and community meetings.

The provider held monthly operations meetings which reviewed data including incidents, medication errors, duty of candour adherence and any further concerns.

Policies which were reviewed as part of the inspection had version control which ensured a review of them had been recorded.

The provider had a business continuity plan, dated October 2024, which covered the relevant areas.

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.

Staff and leaders were open and transparent and collaborated with all relevant external stakeholders and agencies. The provider engaged in various meetings with external stakeholders including the local authority, the ICB and the local hospital. The provider also attended training events including 2 events in 2025 hosted by CQC.

The provider consistently updated and sought guidance and involvement from relevant healthcare professionals, local experts, agencies and advocates. Leaders were regularly involved in multi-disciplinary team meetings with relevant professionals including coordinators, social workers and police officers, from a range of services. These meetings were in the best interests of the people.

The provider documented all feedback, including meetings and meaningful engagements with staff, people and the wider community.

Feedback from stakeholders and other agencies was positive. A staff member from an external agency stated: “I have found the service to be clear and responsive in their communication. Their care planning, risk assessments and formulation of the person are person centred and include their voice.”

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.

The provider was committed in ensuring quality assurance was in place to maintain high standards of care and ensure the well-being of people.

There were clear and established standards for various aspects of care such as medication management and people’s safety. The provider reviewed incidents and medication errors monthly via a quality assurance team and any actions were returned to the registered manager. Any medication errors identified as controlled drugs errors were recorded on the NHS Controlled Drugs reporting portal. A data governance team reported incident compliance each month.

The provider regularly assessed the care provided through audits, mock inspections and by analysing feedback from people and their families. The provider’s mock inspections were undertaken on a monthly rotation for all the providers’ services against the quality statements. The most recent, in January 2025, showed the service was performing well in various aspects including governance and safeguarding.

Data including incident reporting and health outcomes was collected and analysed to identify areas for improvement. Clinical, residential and corporate governance meetings were held monthly to identify areas of concern including employment, financial, strategic and corporate risks, with relevant matters being fed into appropriate operations meetings.

The provider adequately trained staff and they understood the quality standards and procedures.

The provider had adapted the Safewards model from a hospital setting for the benefit of their residential homes.