Ashbury Lodge Residential Home

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 service was not always well-led. This meant the management and leadership was inconsistent. The service was in breach of legal regulation in relation to the governance of the service.
 

This service scored 62 (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 provider had a values statement and policies and procedures, setting out expectations on how staff should work. There was a positive and open culture at the service. The manager told us, “We empower staff, with staff surveys, and ‘you said we did’ [a process where services act on feedback from people]. We also have a suggestions box for staff.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The service had a manager in post who had applied for registration with the Care Quality Commission (CQC). People, relatives and staff were positive about the leaders’ approach and knowledge. A healthcare partner told us they felt improvements had been made since new leaders started working at the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us there were effective systems for them to raise any concerns and they felt confident action would be taken if they used them. The manager explained, ‘The head office has a speak out Guardian [name], staff can go to her if they would like to speak about any concerns. They can also send [any concerns] anonymously.” Details about how to contact this person was recorded in the service’s policy. A staff member also confirmed this was displayed in an office at the service so staff could easily access this information.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have good governance systems to manage the service well. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Leaders had not informed CQC about incidents in line with their statutory requirements. This meant CQC did not have clear oversight of the service from a regulatory perspective, which put people at risk of harm. However, leaders acknowledged this and told us they had taken action to ensure this does not happen again.

The provider’s systems and processes for auditing had not identified issues in relation to health and safety, IPC, risk management, and medicines. This meant the audit systems for identifying, capturing and managing organisational risk and issues were not effective in identifying concerns. We found there was a continued breach from the previous inspection, relating to the governance of the service. This meant the service had not fully learnt from the last inspection.

However, staff were clear about their roles and responsibilities. People, relatives and staff spoke positively about how the service was managed. Comments included, “Very well organised”, and “Excellent”. The manager told us, “We have senior meetings at our head office in [location]; we have away days where good practice is shared throughout the homes [in the organisation]. We have a large support network from our senior management team.” This enabled services to learn from one another and share good practice. Leaders also told us they felt there had been made improvements since the last inspection. One leader told us, "A huge amount of developmental work has been carried out in the service since the last inspection, relating to auditing, risk management plans and leadership. Audits are now not only comprehensive but also used to support staff development and quality of the service."

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.