Aspray 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 demonstrated a positive commitment to celebrating the diversity both for the people using the service and staff. By recognising and valuing different backgrounds, the service adopted an environment where everyone felt respected and included.

A range of events and activities were organised to mark and honour various religions and cultural backgrounds. These initiatives included celebrating religious festivals such as Diwali, Eid, and Christmas, which provided opportunities for participants to share their traditions and beliefs with others.

Sharing traditional foods from different cultures played an important role in these celebrations. By inviting everyone to sample and enjoy dishes from diverse backgrounds, the service encouraged open dialogue and promoted mutual understanding.

Staff told us that they had a good level of job satisfaction and expressed that they felt their voices were heard and valued within the organisation. One staff said, “I feel valued and supported which motivates me to do the best job that I can”.

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 management team told us that they led by example and maintained an ‘open door policy’. This approach encouraged staff members to feel included and supported, which helps give a positive and open working environment.

Staff expressed that they felt supported not only in their professional roles but also in their personal lives, highlighting the holistic and caring culture promoted by the management team. Comments included, “There is always room for improvement with the way the service is being managed, however things have changed for the positive.”. Another staff told us, “Management are very supportive and approachable”. One staff also told us,” The Manager is very supportive to promote confidence and equality at work.”

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

At our last assessment in June 2024, it was identified that improvements were needed around staff speaking up. At this assessment, we found improvements had been made.

People were provided with opportunities to share their views and experiences regarding the care they received. For example, resident meetings were held frequently, creating a forum where people could voice their concerns, offer suggestions, and participate actively in discussions about the quality and delivery of care.

Staff members participated in daily flash meetings designed to facilitate the ongoing review of care practices. These meetings, provided staff with an opportunity to discuss recent developments, address any pressing concerns, and collaboratively review procedures. The purpose of these meetings was to ensure that care remained responsive, effective, and aligned with residents’ needs.

Staff demonstrated a clear understanding of the organisation’s whistleblowing policy. They communicated the purpose of whistleblowing as reporting unsafe or harmful practices when routine reporting channels have not resolved concerns. Comments included, “Whistleblowing is when someone reports wrongdoing they’ve seen in a workplace or in an organisation.

First step is to report to my your line manager or supervisor or Human Resources and the Care quality commission. Another staff said, “Whistleblowing is reporting unsafe or poor practice to management or external bodies.”

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.

Staff reported that they could request reasonable changes to their work schedules to accommodate particular requirements, such as family responsibilities.

We saw that the provider had an up to date equal opportunity policies. These policies were designed to ensure that hiring, promotion, training, and other employment decisions were based solely on merit, without discrimination based on factors such as gender, race, age, disability, or socio-economic background.

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.

During the previous assessment in June 2024, feedback from relatives highlighted concerns regarding the provider’s management of safeguarding and the management of people’s individual risks. Since the last assessment , there have been notable improvements in these areas. The service had strengthened its governance systems, improved record keeping, and enhanced processes for managing risks and learning from safeguarding issues.

These developments have collectively resulted in a safer and more person-centred approach to care for those using the service.

The provider routinely undertakes regular audits and checks in critical domains such as care records, health and safety, and staff practice. These processes were integral to maintaining standards and identifying further opportunities for improvement.

The registered manager and senior staff possessed a clear understanding of the governance systems operating within the service and could articulate their individual responsibilities. This leadership ensured that governance processes were embedded throughout the organisation, promoting accountability and good standards of care.

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.

At our last assessment in June 2024, we identified improvement were required in regard to working with professionals. At this inspection we found improvements had been made.

Staff demonstrated a clear understanding of their responsibility to collaborate and work in partnership, ensuring that services operate seamlessly for people who us the service. This approach encouraged an environment where information and learning were routinely shared with partners, facilitating ongoing improvement and enhanced outcomes.

The management team communicated, with local partners, as well as with health and social care teams. The manager said, “I attend different meetings with stakeholder. I always inform the local authority of any changers to people needs or highlight concerns that they need to be aware of relating to people we support.”

People’s care plans held information of various professionals that supported the person. This ensured that all relevant parties were informed and could contribute effectively to the person’s wellbeing.

Staff, regularly met with professionals directly involved in people’s care and support. These meetings enabled ongoing communication, coordination, and collaborative decision-making, further improving the quality and consistency of care provided.

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.

We found at this assessment; the service had made positive improvements since our last assessment in June 2024.

Feedback indicated that people were individually consulted during reviews or regular conversations, enabling them to voice any concerns or requests.

Staff members reported that managers consistently aimed to improve the service for the benefit of those using it. Staff enjoyed contributing to these efforts. The provider established regular staff forums, offering staff a constructive platform to share their views and participate in service development. Comments included, “I feel as a team we learn from each other.” Another staff member said, “The manager communications to staff of any learning from incidents and if any adjustment or changers are taking place to help improve the service.”