Archived: Ashingdon Hall

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

At our last assessment to the service in December 2023, we found the provider’s quality assurance arrangements to be ineffective. This was a breach of Regulation 17 [Good governance] of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. We found at this assessment not enough improvement had been made and the provider remained in continued breach of Regulation 17.

Although people implied the service was well managed and led, significant improvements were still required to the service’s quality assurance arrangements as shortfalls identified at this assessment were not identified by the service and the overall governance of the service at both provider and service level remained a concern.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager and staff were not able to provide us with an overview of the provider’s ethos or values. Staff were not kept informed of developments and the provider did not act in an open and transparent manner about the wider and significant failings in the service.

There were no meetings held at Ashingdon Hall for people using the service or for relatives. No consideration had been made to develop a newsletter to keep people up to date and demonstrate the service’s successes and improvements that were being made.

The manager was unable to demonstrate a good knowledge and understanding of regulatory requirements, which are necessary and which providers must meet when providing care. The manager told us that although they were aware of the Care Quality Commission’s new Single Assessment Framework methodology introduced in Essex in January 2024, they had only viewed this the day prior to the commencement of this assessment.

There remained no registered manager at Ashingdon Hall, despite the requirement on the provider to have one in place. The service has not had a registered manager since January 2023. The current manager had applied for a DBS check but had not yet completed or submitted their application to be registered with the Care Quality Commission as they did not know how to do this. The manager had been the deputy manager at our inspection in December 2023. The previous manager resigned in July 2024, whereby the deputy manager was promoted to the role of manager by the provider. The manager had not received a revised job description or an induction to their new role. The manager told us they had not been supported by the provider in their new role despite numerous verbal requests for support and assistance. The only support provided to date was from the newly appointed regional manager, who commenced in post, the day prior to this assessment. The manager told us they felt overwhelmed with their current workload and the ongoing developments at the service.

Procedures were now in place for gathering staff’s views relating to their employment and what it was like to work at Ashingdon Hall. These were conducted in July 2024 but only 2 members of staff had completed and returned the surveys. No action had been taken to review staff morale, experiences and to drive improvements at the service.

Arrangements were now in place for gathering people’s and relative’s views relating to the quality of the service provided at Ashingdon Hall. Surveys for people using the service had been conducted with staff, with all scores either scoring 3, 4 or 5, with 1 being poor and 5 being excellent. We found 3 relatives surveys were completed and returned. All scores recorded were either 4 or 5. A relative’s comments recorded, “X is very well cared for and the staff very attentive.” Where 1 relative had raised issues that required a response and action, the manager had responded positively.

There was a diverse workforce at Ashingdon Hall, with staff employed from a wide range of backgrounds, cultures and experiences. The manager could not give examples of how they and the provider created a compassionate, collaborative, inclusive, positive culture at Ashingdon Hall. Staff confirmed there were few opportunities to discuss their development through supervision and staff meetings.

As stated previously within the ‘Caring’ section of this report, staff did not have regular opportunities to attend staff meetings, to provide feedback, raise concerns and suggest ways to improve the service or staff experience. Staff meetings were not routinely held to give the management team and staff the opportunity to express their views and opinions on the day-to-day running of the service. Since our last inspection in December 2023, only 2 staff meetings had been held and one of those was a senior management meeting. Staff meetings can be used to discuss important matters, share updates and boost staff morale. Information was not readily available and displayed for staff relating to possible wellbeing initiatives.

The manager confirmed they were worried about the service’s level of compliance with regulatory requirements. They told us they were aware that their own knowledge and understanding of compliance was deficient but would have welcomed guidance and support if this had been readily available and from an external source.

Quality assurance arrangements remained unreliable. The provider was unable to demonstrate effective oversight of the service. There was no expectation on the manager to complete and forward regular reports to the provider, summarising progress with regulatory requirements. For example, audits, outcomes and actions taken to address where improvements were required. The provider had not delegated a representative in the absence of a registered manager sooner to ensure effective oversight. This should be used to help the provider and manager, drive improvement, including the monitoring of trends and lessons learned. The provider was unable to effectively implement improvements to drive the quality of care at the service, leading to delays and incomplete actions.

The quality assurance and governance arrangements in place were not effective in identifying shortfalls. This referred to continued non-compliance with the Mental Capacity Act. Risks to people’s safety were identified and not routinely recorded. Required recruitment checks on staff were not always made, including receiving a robust induction. Not all staff received up dated training or had their performance adequately monitored.

A Service Improvement Plan was sent to us in October 2024, but the manager told us they had not been involved with its development. We were not assured the person who completed the plan had sufficient knowledge of Ashingdon Hall or were retaining oversight of its progress. We found that some information recorded within this plan was not accurate, providing an inaccurate and flawed picture of progress. The plan recorded staff personnel files would be audited for compliance, and this was completed in July 2024. There was no evidence to demonstrate staff files had been audited.

Effective systems to monitor and improve the quality of the service were not in place. This was a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities)

The manager was not able to demonstrate how they developed their knowledge and kept up to date with local developments, other than by accessing the provider’s policies and procedures and Care Quality Commission’s website. The manager was unaware of other resources, such as, webinars and local network groups. The regional manager told us they would address this with the manager going forward.

Arrangements were not in place to engage with people, communities, and partners to share learning that resulted in continuous improvements to the service. There was no evidence to demonstrate how new or innovative ideas that can lead to better outcomes for people had been considered. The provider had only recently employed a regional manager to oversee all of their services and help bring about change at Ashingdon Hall.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.