Pathfinder Ashness 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

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 inspection, the rating has remained good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were aware of and aligned with the service’s vision, applying its principles in their daily work. Staff were able to describe their collaborative approach to delivering patient care, highlighting effective teamwork and communication.

Staff had the opportunity to contribute to discussions about changes within the service. For example, about changes to the staff room, and changes to shift patterns where required.

Managers had the necessary skills, knowledge, and experience to effectively lead and manage their team. They had a good understanding of the service they managed and were able to explain how the team worked together to provide care to their patients. At the time of the inspection, the hospital director had been in post for 1 year.

Staff praised managers for being visible, approachable, and supportive, fostering a positive working environment. Senior staff demonstrated a proactive approach, swiftly addressing areas for improvement and driving positive change.

Development opportunities were available. The Clinical Services Manager was attending an Infection Prevention and Control course.

Staff we spoke with stated that they felt able to raise concerns and were aware of the whistleblowing policy.

The provider had a freedom to speak up policy and system in place. This information was displayed for staff to see and there was a freedom to speak up champion.

Patients had opportunities to give feedback on the service they received. For example, through community meetings, one-to-ones with staff and the complaints form. However, staff shared that the attendance numbers at community meetings were minimal.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Patients were included in deciding their food menu to suit their needs. Carer forums were held approximately every four months to provide an opportunity for the family/carers of patients to meet staff, ask questions about the service and access peer support from other carers. Staff encourage feedback, to adapt to the identified needs and preferences of the carers.

Leaders appeared mindful about potential discrimination and inequality that might affect diverse staff groups. One staff member said they felt supported by managers around their needs. When on site, we didn’t observe a lot of information in relation to LGTBQ+ or other areas where a staff member may feel marginalised by society, which would have supported an open and welcoming atmosphere.

The findings from the other key questions indicated that localised governance processes were largely effective in identifying issues and implementing improvements. There were a small number of areas where the service did not have clear process or policies, or where policies were not being implemented as they should be. This included the search and visit policy and the robust management of sexual safety on the wards.

The service had a structured framework for team and governance meetings, ensuring discussion of key topics, including incident learning and complaints, to drive improvement.

Managers held regular monthly governance meetings to review key areas, including health and safety, incidents, audits, and complaints, promoting a culture of transparency and improvement.

Managers and senior staff effectively addressed performance issues. Managers and senior staff had access to a range of information about the performance of the service, staffing and patient care.

Staff were aware of how to report incidents via their internal system, and incidents were regularly discussed in team meetings, driving learning and improvement from recent incidents.

The service raised safeguarding concerns when needed with the local authority.

The service had a local risk register, maintained by the hospital director. The service had a business continuity recovery plan in place. They had plans for emergency situations, such as, a loss of electricity, a fire or water leakages.

Leaders understood who their partners and communities were and engaged with external stakeholders, for example, commissioners and care coordinators.

Patients, carers and staff could meet with members of the service’s senior leadership team to give feedback.

The service developed links with services in the community to support patient engagement in community activities.

Staff were offered opportunities to develop and reflect. Mandatory training, supervision and appraisals were available to all staff.

Team meetings, nursing forums and clinical governance meetings all took place in line with their recommended time frames.