Ashlong Cottage

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 legal regulation in relation to how well the service was governed.

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 team worked closely together, with a strong emphasis on meeting people’s individual care needs. The registered manager told us staff turnover was low, which promoted consistency and continuity of care. Several staff members had worked at the service for many years, enabling them to develop a good understanding of people’s needs, preferences, and routines. Some staff had progressed within the organisation, having initially joined as support workers before moving into senior roles, which demonstrated opportunities for development and helped retain experienced 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.

There was a clear management structure with shared responsibilities that supported the effective day-to-day operation of the service. The registered manager was actively involved in the running of the service and demonstrated a good knowledge of people’s individual support needs. Family members told us the registered manager was approachable, responsive, and kept them informed about the care and support their relatives received.

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

Staff were knowledgeable about the whistleblowing procedure and understood their responsibility to raise concerns when necessary. One staff member told us, “It's about the reporting outside the home should I need to share information that is concerning." The registered manager told us there was an open-door policy and that staff were encouraged to raise any concerns, issues, or suggestions.

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.

Staff had access to the provider’s diversity and inclusion policy, which outlined the principles of a diverse and inclusive workplace, ensuring that staff felt valued and respected. Feedback from staff about the management team was positive. One staff member said, "The [registered] manager is very supportive. He is mentioning and giving opportunities to develop and easy to approach.”

The provider did not have good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Records demonstrated that staff at all levels were responsible for carrying out checks to monitor and oversee the delivery of care. However, there was no formal auditing process in place to monitor the activities provided within the home. Although the registered manager carried out observations of staff facilitating activities, there was no effective system in place to oversee whether meaningful activities were being offered to people on an ongoing basis, how frequently they were taking place, or the level of people’s engagement. Our review of activity records identified several gaps where records had not been completed. Where records were available, they contained limited information and did not clearly demonstrate the choices offered to people, the duration of activities undertaken, or the level of each person's involvement. This limited the provider’s ability to assess whether activities were appropriate, person-centred, and reflective of people’s individual needs and preferences. In addition, the governance systems in place had also failed to identify the issues we found regarding the review of mental capacity assessments and the accuracy of care records in reflecting people’s current support needs.

This meant that the quality assurance processes in place were not sufficiently robust to provide effective oversight of people’s engagement in activities and the support provided. We found a breach of Regulation in relation to governance.

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.

The home worked collaboratively with healthcare professionals to support people’s health and wellbeing. The most recent referrals had been made via the GP to Psychiatry, Occupational Therapy, and Physiotherapy services to meet individuals’ assessed needs. This helped to ensure that people received safe, effective, and person-centred care.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Ongoing monitoring and improvement were evident, with actions identified and addressed in a timely manner. The registered manager utilised the monthly audit spreadsheet to record the necessary actions. Once completed, these actions were clearly marked as such.