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 inadequate. At this assessment the rating has remained 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 continued 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 had not created a positive and inclusive culture that ensured high-quality care was consistently delivered.

Staff and relatives described challenges in maintaining a consistent workforce. One relative said, "The last 6 months have been unsettling and staff coming and going." This reflected wider concerns regarding workforce stability and continuity of care.

During and following the assessment, we received whistleblowing information which raised concerns about standards of care and the culture within the service. The concerns raised did not reflect a culture that consistently promoted openness, transparency and learning.

Our findings demonstrated leaders had not always been effective in embedding and sustaining improvements. Concerns identified at previous assessments remained evident during this assessment, including concerns relating to care planning, risk management, monitoring, communication, staffing and infection prevention and control. This demonstrated previous learning had not consistently resulted in sustainable improvements for people.

Although the provider had introduced new systems and processes to drive improvement, our findings demonstrated these had not been fully embedded into practice. As a result, leaders had not established a culture capable of consistently achieving and maintaining the standards people had a right to expect.

The provider did not always have leaders with the capacity, capability and oversight required to ensure people consistently received safe, effective and high-quality care.

The provider told us they had been driving improvements across the service and had introduced new systems, processes and external support to strengthen the quality of care provided. However, our findings demonstrated concerns remained across multiple areas of the service, including care planning, risk management, monitoring, medicines management, communication, infection prevention and control and staffing. This meant leaders had not been effective in embedding and sustaining improvements.

Concerns identified at previous assessments also remained evident during this assessment. Whilst some improvements had been made, changes were not fully embedded or implemented by staff into day-to-day practice. This indicated improvement activity had not consistently resulted in sustainable improvements for people.

During the assessment, the provider responded to concerns raised and took action to address some of the issues identified. However, a number of concerns found during the inspection had not been identified through the provider's own monitoring and oversight processes. This showed they did not have a full understanding of the quality and safety of the service or the lived experiences of people using it.

As a result, leaders did not always demonstrate they had the capability, capacity and oversight required to consistently achieve and maintain the standards people had a right to expect.

The provider did not always promote a culture where people felt empowered to speak up and be assured their concerns would be listened to and acted upon.

During and following the assessment, we received whistleblowing information which raised concerns about standards of care, staffing and the culture within the service. The concerns raised indicated staff did not always feel issues had been effectively addressed and did not consistently reflect a culture that promoted openness, transparency and learning.

Our findings also identified concerns that had not been recognised or addressed through the provider's own systems and processes prior to the assessment. This included concerns relating to care planning, risk management, monitoring, medicines management and staffing arrangements. This did not provide assurance concerns raised by staff and opportunities for improvement were consistently identified and acted upon.

However, some staff told us they felt able to approach managers and raise concerns where necessary.

Whilst some staff feedback was positive, the whistleblowing information received and wider findings from the assessment did not provide assurance there was a consistently open culture where people felt fully empowered to speak up and drive improvement.

The provider did not always demonstrate how equality, diversity and inclusion were embedded within the workforce.

During the assessment, concerns were identified regarding whether staff were consistently enabled to provide inclusive care that reflected people's individual needs, including communication needs. This did not provide assurance that staff had the information, guidance and support required to provide inclusive care to all people using the service.

However, staff we spoke with did not raise concerns regarding discrimination, exclusion or unfair treatment.

The provider did not have effective governance systems to identify, monitor and address risks. Leaders did not always have effective oversight of the quality and safety of the service.

Throughout the assessment, we identified concerns which had not been recognised or addressed through the provider's own audits, monitoring systems and oversight processes. These included concerns relating to care planning, risk management, medicines management, infection prevention and control, staffing, communication and the monitoring of people's care. We also identified environmental concerns, inaccuracies within care records and monitoring gaps which had not been effectively identified through the provider's governance systems.

Governance systems were not effective in identifying concerns or driving improvement. Care plans and risk assessments were not always accurate, complete or reflective of people's current needs. Monitoring records contained gaps and inconsistencies, and provider oversight systems had not identified concerns relating to repositioning records, medicines disposal processes, environmental risks and aspects of people's care and support. This meant opportunities to identify risks and take timely action were missed.

Staffing records did not always provide clear oversight of workforce deployment. For example, agency staff were not identified by name on rota records and leaders were unaware of who was on shift. This limited assurance there was effective oversight of staffing arrangements and the skills, knowledge and experience available on each shift.

Concerns identified at previous assessments remained evident during this assessment. Whilst the provider had introduced new systems, audits and external support to drive improvement, these had not consistently identified the concerns found during our assessment. This demonstrated governance arrangements were not effective in identifying risks, ensuring compliance or driving sustainable improvement across the service. As a result, governance, and management arrangements were not effective in ensuring people consistently received safe, effective and high-quality care.

The provider did not always ensure partnership working resulted in improved outcomes for people.

The local authority was providing ongoing oversight of the service and supporting the provider to make improvements. This included regular visits to monitor progress and to provide support.

The provider also made referrals to relevant healthcare professionals after we raised concerns. However, assessment findings demonstrated that some improvements arising from this involvement had not yet been fully embedded into day-to-day practice. For example, concerns remained regarding care planning, risk management and staff understanding of people's dietary needs.

Whilst partnership working was taking place, information, advice and improvements arising from this support had not been consistently translated into practice to improve outcomes for people.

The provider did not demonstrate an effective approach to learning, improvement and innovation. Opportunities to learn from incidents, concerns and previous findings had not consistently resulted in sustained improvements for people.

Concerns identified at previous assessments remained evident during this assessment. We found ongoing issues relating to care planning, risk management, monitoring, medicines management, infection prevention and control and staffing. This demonstrated previous learning had not been effectively embedded into practice and improvements had not been sustained.

Systems for identifying, reviewing and learning from incidents were not always effective. As a result, opportunities to review, investigate and learn from incidents were missed.

We also identified concerns that had not been recognised through the provider's own systems prior to our assessment. This included inaccuracies within care records, monitoring concerns, medicines management issues and environmental risks. This did not provide assurance systems were effective in identifying emerging concerns and driving improvement.

Although the provider had introduced new systems, audits and external support to drive improvement, our findings demonstrated these measures had not been fully embedded and had not consistently achieved the required standards. As a result, we found the provider's approach to learning and improvement was not effective in delivering sustainable change and positive outcomes for people.