Ashley Court Care Limited

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 was rated requires improvement. At this assessment the rating has changed to inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of the legal regulation in relation to governance at the service.

This service scored 36 (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 did not have a shared vision, strategy and culture based on transparency.
There was a lack of openness and transparency from the leaders. For example, we were told a person’s pressure mattress was not working as there was a power cut in the home, however we saw the plug was loose and other electrics in the room were working. We were told another person’s care file was written in their preferred language when we viewed this it was not. The deputy manager told us they held a qualification in moving and handling when we requested evidence to support this, we were told this was not accurate. This demonstrated a poor culture at the service.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.
The lack of systems and oversight of the care people received demonstrated a lack of capability within the management and leadership team. There was a failure by all leaders to have adequate oversight of the home. Including the lack of oversight on staffing levels, the treatment of people and the competency of staff.
Furthermore, when we shared concerns about the environment the leadership team did not recognise the concerns or accept the accuracy of this. We had to show the provider evidence of this before they acknowledged the concerns. There was a lack of accountability and understanding from the provider about the serious concerns we found during our inspection.
 

The culture of the service meant the provider failed to work transparently. The provider had failed to develop an open and honest culture where they consistently worked openly with people, their families and other professionals to share concerns.
People and relatives knew how to raise concerns however they felt they were not always acted upon. A relative said, “I have made complaints about the cleaning and laundry going missing, it improves for a while, then slips back. I have made another complaint about the cleaning yesterday”. The failure to act on concerns and make positive changes meant people may stop speaking up.
There was a complaints procedure in place. There was also a whistleblowing policy in place and staff were aware of this and the procedures they needed to follow.

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 felt they were treated in an inclusive way, and their needs were considered, however we were not provided with evidence or examples of this.
There were procedures in place to consider staff’s individual needs, which included considering staff’s diverse needs and treating all staff fairly and equitably.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.
After our last inspection we raised our concerns around the governance of the service. At this inspection we again found the same concerns. The systems the provider had introduced had not been effective in making improvements to the home and the care people received, which had resulted in continued breaches of the legal regulations.

Some audits had been introduced since our last inspection; however, they were not effective in keeping people safe, identifying concerns and driving improvements through the service. For example, the environmental audit and the IPC audit had not identified the concerns we have reported upon.

There remained a lack of oversight and people continued to receive unsafe care. Since our last inspection the provider had introduced an audit of people’s care plans and records, this had failed to identify people’s information was incorrectly completed.

The provider had not followed their own policies to keep people safe. For example, their bed rails and CCTV policies had not been followed. The system in place to ensure there were enough staff available was not accurately completed and therefore not effective. The systems to manage training in the home had not identified staff had not received a specific training relating to someone’s health and they had failed to ensure the principles of the Menal Capacity Act (2005) were followed.
 

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people.
The provider did not always work effectively with health professionals as referrals had not always been made where needed. This was in relation to people’s mobility needs and equipment.
We spoke with the local authority before the inspection who had told us they were currently working with the provider on an action plan that they had put into place.
There remained no effective systems in place to ensure they worked in partnership with other agencies, as there was a lack of up-to-date information and oversight of people’s care. When changes occurred, information was not always documented. This meant people were at risk of receiving unsafe and unsuitable care.
 

There was a lack of effective systems in place to identify concerns and drive improvements, which meant learning opportunities were missed.
The provider told us there had been a lot of learning and changes since our last inspection, however when asked they were unable to provide evidence to support this, we gave them the opportunity to send this to us after our inspection, however the information they sent did not demonstrate an improved service. Lessons from previous failings had not been learnt.
The systems in place were not effective and had not identified all concerns and driven improvements, which meant learning opportunities were continually missed.