Ashfield House - Raunds

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 governance at the service.

This service scored 61 (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 and culture focused on providing person-centred care, promoting people’s wellbeing and treating people with dignity and respect. The provider’s values promoted wellness, happiness and kindness.

The registered manager had worked at the service for a long time before being promoted to the manager role. They knew the service, people and staff well and demonstrated a commitment to providing good quality care.

Staff generally spoke positively about working at the service and described good teamwork. They understood their roles and demonstrated a commitment to supporting people in a caring and respectful way. People and relatives were also generally positive about staff and the care they received.One staff member told us, “I think mainly all of us are a very caring team and work well together to ensure we provide our best care to the service users.”

Overall, there was a positive and supportive culture within the service, with leaders and staff sharing a commitment to providing good quality, person-centred care.

The provider did not always make sure leaders had a clear and accurate understanding of the quality of care being provided or the risks and challenges within the service.

Staff generally spoke positively about the management team and described leaders as approachable, supportive and available when they needed advice or guidance. Staff felt supported through regular meetings and supervision. One staff member told us, “I am very happy at Ashfield House. The management have been supportive and are very approachable.”Relatives also generally described management as approachable. The provider understood their responsibilities in relation to Duty of Candour and notifying CQC of significant events.

However, during our assessment, we identified concerns which had not been fully recognised or addressed by leaders. These included areas relating to people’s safety, staffing pressures, care records and the effectiveness of monitoring and oversight. This meant some risks and areas requiring improvement had not been identified or addressed effectively.

Overall, leaders were approachable and supportive, and staff generally spoke positively about them. However, improvements were needed to strengthen leadership oversight and make sure risks and areas requiring improvement were consistently identified and addressed.

The provider supported a culture where staff felt able to speak up and raise concerns without fear of negative consequences.

Staff described managers as approachable and supportive and told us they felt able to raise concerns about people’s care or the running of the service. The provider had a whistleblowing policy, and staff understood their responsibility to report poor practice or concerns.Staff meetings and supervision provided further opportunities for staff to raise issues. People and relatives also generally felt able to approach staff and management with concerns when needed.

Overall, there was an open culture where staff, people and relatives felt able to speak up and raise concerns.

The provider promoted an inclusive and fair working environment and valued diversity within its workforce.

Equality, diversity and inclusion policies were in place. Staff were recruited through fair recruitment processes and had access to training, supervision and opportunities for development.Staff described positive working relationships and good teamwork. They felt supported by colleagues and managers and did not raise concerns with us about discrimination or unfair treatment. The provider also had arrangements in place to support staff wellbeing and recognise their contribution.

Overall, the provider promoted an inclusive working environment where staff from different backgrounds were supported and treated fairly.

The provider did not have effective governance and oversight systems to consistently assess, monitor and improve the quality and safety of the service.

The provider had a range of audits, checks, manager walkarounds and monitoring systems in place. However, these did not consistently identify, or address concerns found during our assessment. For example, care plan audits had not identified missing, inaccurate or contradictory information in people’s records. This included unclear or inconsistent guidance for managing known risks and clinical needs, including recurrent falls, pressure care and catheter care. We also found discrepancies in medicine stocks. This showed checks were not always effective in making sure information used to support and monitor people’s care was accurate.

The provider monitored incidents and risks, including falls. However, where recurring risks had been identified, there was limited evidence that actions taken were consistently evaluated to demonstrate they had reduced further incidents. This meant governance systems did not always provide assurance that learning from incidents resulted in effective and sustained improvements.Management of environmental checks had not identified some concerns we found, including stained furniture, risks associated with an unrestricted kitchenette, gaps in cleaning records and empty hand sanitiser dispensers. We also observed communal areas without sufficient staff supervision, including where people were at risk of falls.

We found concerns about the reliability of some monitoring records. Records for people requiring regular wellbeing checks had not been completed at the required times. We later observed staff completing several entries together. This meant we could not be assured checks had taken place as recorded. Oversight of complaints and concerns also required improvement. There was limited evidence that verbal or informal concerns were consistently recorded and monitored in line with the provider’s policy, reducing opportunities to identify themes, trends and learning. The provider used a dependency tool to calculate staffing requirements. However, concerns identified elsewhere regarding staff deployment and supervision meant the provider could not be fully assured that staffing arrangements consistently reflected people’s needs and risks.

Management oversight of staff practices also required improvement. We observed inconsistent infection prevention practices, including the use of gloves during mealtimes despite staff trained in this area. The provider also used a ‘Policy of the Month’ system to support staff awareness of policies, but records showed only a small number of staff had signed to confirm they had read the selected policy.Governance systems had not identified that call-bell records did not provide reliable information about actual staff response times, limiting the provider’s ability to monitor whether people received timely assistance.

Overall, although governance and monitoring systems were in place, there were significant and widespread shortfalls in their effectiveness. Systems had repeatedly failed to identify, address and learn from concerns across several areas of the service, including people’s safety, care records, monitoring, staffing, staff practice, the environment and complaints. This meant the provider could not consistently assure itself that risks were effectively managed or that people received safe and good-quality care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked in partnership with other organisations and the local community to support people’s care and wellbeing.The service worked with a range of health and social care professionals, including GPs, district nurses, social workers, falls teams and other specialist services. Staff contacted relevant professionals when people’s needs changed and sought advice and support when needed.

The service had also developed links with the local school, nursery, church and local authorities. These partnerships provided opportunities for people to remain connected with their local community. The provider worked with families and those important to people to help coordinate their care and support.

Overall, the provider worked positively with families, health and social care professionals and community organisations to support people’s health, wellbeing and community involvement.

The provider had systems in place to identify learning and make improvements. However, these did not always lead to effective or sustained improvements.

The provider used information from incidents, monthly analysis and governance audits to identify areas for improvement, including falls, infections, safeguarding concerns and pressure damage. Actions included referrals to healthcare professionals, updates to care plans and risk assessments, and additional equipment. However, where recurring risks were identified, there was limited evidence of clear improvement plans or checks to show whether actions had reduced those risks.

A ‘quality of life’ audit completed in February 2026 identified areas for improvement, and the provider had taken action in response to some findings. However, during our assessment, some concerns remained, including learning from incident, activities and Mental Capacity Act and decision making records. This showed that some improvements had not been fully implemented or sustained.There was also limited evidence that themes and lessons from incidents and other monitoring were consistently turned into clear actions, shared with staff and reviewed to make sure improvements were effective.The provider was receptive to feedback during our assessment and took action to address a number of concerns when these were brought to their attention.

Overall, the provider demonstrated a willingness to learn and improve. However, improvements were needed to make sure learning resulted in clear actions that were implemented, monitored and sustained.