Ashgale 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 changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of a legal regulation in relation to good governance. The provider did not have effective governance and quality assurance systems to monitor, assess and the improve the quality of the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the provider had established a clear vision, strategy, and culture promoting transparency, equity, equality and human rights, observations and team meeting minutes indicated that some of these values were not yet fully embraced by all staff and consistently embedded across all care practices.

Leaders had not always ensured that autistic people and people with a learning disability lived ordinary lives. There was a lack of provider oversight to ensure people were supported to grow their independence and have access to activities that were meaningful to them. The service leaders and staff focused on ensuring people’s basic needs were met without supporting people to develop and grow.

Notwithstanding the above, staff reported that the registered manager was approachable and easy to talk to if they needed to raise any concerns. A staff member said, “I feel listened to and can bring ideas for improvement to the manager.”

The leaders did not always understand the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their organisation. Leaders did not always have the skills and knowledge, to lead effectively.

While the registered manager was regularly present in the service, implementation and monitoring of systems and processes were not sufficiently effective to identify, address and mitigate risks and quality shortfalls within the service. This lack of effective oversight impacted the provider’s ability to ensure good governance, regulatory compliance, and consistent improvements in the quality and safety of care.

However, staff were positive about the management team and felt engaged by them in all aspects of the care delivered. Following concerns raised during our assessment, the registered manager was receptive to our feedback and assured us that appropriate actions would be taken to address and rectify the concerns identified.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt comfortable raising concerns and would feel safe to whistleblow if needed. Comments included “I would feel ok raising a concern.” Staff told us they trusted the registered manager and felt listened to. There were clear whistleblowing and safeguarding policies in place that aligned with national 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.

People were supported by a diverse staff team, reflecting the diversity of the people living at the service. This enabled staff to readily identify and meet people’s cultural needs and preferences.

Staff told us that the registered manager and provider treated staff equally and had not observed discrimination.

The provider had an equality and diversity policy, and staff had completed equality, diversity and inclusion training.

The provider has not effectively implemented their quality assurance and governance systems and processes at Ashgale House which meant they had not identified safety and quality shortfalls at the service so the necessary improvements could be made.

The registered manager was completing audits of the quality of care at Ashgale House. However, we found these were not always effective. For example their checks and observations of the planned care that people received had not identified the concerns we had found in terms of shortfalls in the care of people and the management of the risks of choking. These checks and observations have also not identified that people were not always receiving the care and support in relation to their social care needs and development.

We also found that the care records audits/checks have not identified that care plans and risk assessments were not always up to date or included current information about the care of people or that the planned care of people were not always being implemented such as those related to their social care needs. The medicines audits had also not identified shortfalls we found in relation to the management of medicines.

The arrangements in place to ensure that the provider was appropriately managing circumstances where there were restrictions on people’s liberty were not always effective. We did not always find documented evidence to show that where there were restrictions on people’s liberty that the least restrictive option had been considered and that an assessment had been carried out to demonstrate that these were in the best interests of the person.

While the provider understood their duty to collaborate and work in partnership to ensure services worked seamlessly for people, this did not always happen in practice.

We found that the provider had not consistently made relevant referrals to support people’s changing health needs to relevant health professionals. This meant that people were not always supported according to their needs putting them at risk of harm and poor and inappropriate care.

The manager had a good knowledge of local health and social care partners, alongside demonstrating a clear commitment to exploring and strengthening relationships. The manager recognised the need to involve others more consistently in care reviews and service development. The provider worked with professionals where people had specific long-term health conditions to ensure they receive the care they needed.

The provider did not always focus on continuous learning, innovation and improvement across the service. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe and effective practice.

When we visited the service, we found a lack of focus and motivation on making sure the service was continuously improving care practices and seeking innovative ways to care for people or for people to receive the care planned for them.

Although the provider had processes to seek feedback from people, their relatives, staff and other professionals for example through satisfaction surveys, the process was not effectively applied to ensure learning and improvement took place. This was because the information gathered was not always analysed comprehensively to identify themes and patterns so action plans could be drawn up to address identified shortfalls. As a result, opportunities to monitor and enhance the quality of care were missed.

The outcomes of the assessment have shown that due to weaknesses in the implementation of the governance and quality assurance systems within the service and the lack of attention to detail, there was limited scope for the service to learn and to continuously improve.