Ashring 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 Good. At this assessment the rating has remained 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 68 (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 management team had a clear vision of the future and direction of the service which put people at the centre of any development, changes and improvements. A manager had been recently recruited and would be in post in December 2025. In the meantime, the senior management team were supporting the service and implementing changes to the documentation.

Staff spoke to us about the vision and culture of the service. Most staff said that the management team were approachable, listened, and that they feel well supported. Some staff found having different senior managers overseeing the service, confusing, but were looking forward to the newly appointed manager starting. They said that things had improved, they were working as a team and felt the home was definitely going in a good direction. One new member of staff said, they had feel welcomed to the home and were really enjoying their induction and getting to know the people who lived there. It was acknowledged that there had been a troubled few months with whistleblowers and safeguards but felt they had been investigated transparently, and in full, and lessons learnt to take forward. A representative of the organisations human resources team had visited the service to talk with staff and gain feedback and offer support.

Staff supported people’s (and staffs’) cultural and spiritual needs. People were treated equally, and their individual needs were met in line with their preferences. The management team were knowledgeable and worked alongside staff to support and promote good practice.
Feedback from staff was in the main positive when we spoke with them. The service aimed to give people consistently good care and staff worked together to try and achieve this. Individual staff supervision and group team meetings were used by the provider to remind staff about their organisations underlying core values and principles. The viewed staff meeting minutes also thanked the staff for their commitment to the people who lived in Ashring House.

Leaders had the skills, knowledge, experience and credibility to lead effectively.

The management team was committed to improvement and was open and transparent regarding the improvements made and those that were on going. We were told that the focus of the service was to ensure people were safe and supported with understanding.

There were systems and processes in place to support staff development and progression within their roles. They talked of how they were supported to attend training, gain qualifications and extend their role, for example becoming a medicine giver. Staff supervisions, and competency check took place.

Staff had not always felt they could speak up and that their voice would be heard. CQC had received a high number of anonymous whistleblowing concerns. However, they have also told us that things had improved. One staff member said, “We are given opportunities to talk to senior staff, I feel I can bring up concerns and be heard.” Formal and recorded opportunities for staff to speak up included staff surveys, team meetings and supervisions. Staff were aware of the whistle blowing policy and felt that they could raise concerns and be listened to. The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance.

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 management team encouraged and supported open communication and there was an open-door policy. The home was proud to be inclusive and supported both staff and people that used the service. The staff team was multicultural, and everyone was respectful of each other.
The provider had procedures in place to promote staff well-being and worked to provide flexible working conditions if required. There were robust measures in place to monitor, maintain and promote good mental well-being across the staff group. There was a formal recruitment process and an equality, diversity and inclusion policy in place to guide equitable and fair recruitment and selection procedures. Staff were encouraged to undertake training in equality and diversity.

The provider had clear responsibilities, roles, systems of accountability and good governance.

Quality assurance systems were in place, however these had not always been used effectively to consistently improve the service. The management team had worked hard over the past few months to introduce robust oversight and effective governance at the service. There were still areas to improve, and this was acknowledged by the management team. For example, improving care plans and risk assessments, daily log documenting, and introducing a more active social life for people to reach their full potential.

Governance meetings were held regularly and minuted. These were used to monitor effectively and pick up trends/concerns early.

Staff told us about their duties and responsibilities; they told us how they managed risk and reported concerns to management. Managers and staff understood their roles, and were clear about quality performance, risks and regulatory requirements. There were checks and audits in place to monitor quality and safety. Action was taken when audits identified areas for improvement. We have received actions plans which have been updated during the assessment process.

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.

People were consistently supported across a range of different services and agencies. There were established systems in place to liaise with other professionals. One professional said, “Communication is pretty good and they contact us in a timely manner to meet the needs of the people in their care.” The provider told us they were being supported by the local authority, to look at systems and improve the service. In addition, within the organisation there were regular meetings and conferences that staff and leaders attended. These were opportunities to share knowledge and learning and consider future developments.

For the purpose of this report, we have concentrated on the period from May 2025 to present day due to changes to the management team and documentation for this key question. The provider focused on continuous learning, innovation and improvement across the organisation and local system. The provider had used the multiple concerns raised anonymously since May 2025 to reflect on practices and improve the service. The concerns have been investigated alongside the local authority safeguarding team, and an action plan had been agreed and was being consistently worked on. We therefore saw example of lessons learnt following incidents which occurred within the service.

People and their relatives had opportunities to feedback their views about the service and quality of the care they received. People and relatives all described the staff and management of the service as open and approachable and much improved. Complaints were taken seriously and learning from them taken forward. Learning was, where appropriate, also shared across the providers other services. The management team encouraged staff to speak up about positive ideas.