Ashton Lodge of Sunbury-on-Thames

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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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.

People and their relatives told us there had been significant improvements since the last inspection. They told us the management team listened and that there was a positive culture at the service. A relative told us, “There is always a happy atmosphere here and they always make me welcome when I visit.” Another relative commented, “Ashton Lodge is a good home in most matters. The only problems I have experienced were about a year ago when they (the service) often struggled to come back with answers after I raised issues, but they have improved a lot recently.”
 

Staff spoke positively about the culture and leadership of the service. One member of staff told us, “100%, it’s a good culture. I have worked in other places. The culture is good now.” Another member of staff said, “[Registered manager] supports us. [I’ve] been here for [number of] years.”
The registered manager told us, “[We have] evolved a lot since the last inspection and strive for outstanding care. The team feels like it has become more united.”
 

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.

People, their relatives and staff told us leaders were approachable and that they had confidence they would take the time to listen. One person told us, “I have never met a person here that I don’t like or get on with.” One relative told us, “I have a very good relationship with both of the floor leaders here.” Staff told us they felt leaders were approachable and supported them to undertake their role. A member of staff told us, “The manager has done lots of things and made lots of improvements. If we need anything for the residents, we only have to ask her and she will get it for us.”

 

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

The provider ensured there was a ‘Raising concerns, freedom to speak up and whistleblowing’ policy and procedure in place and staff told us they felt able to speak up. One member of staff told us, “If I see something wrong it is my duty to speak up.”

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 completed training for equality, diversity and inclusion and told us they felt valued and respected. The provider ensured that staff were supported in relation to their protected characteristics, cultural and religious preferences. For example, where staff required adjustments to be made in order to work effectively, records showed that the provider had worked with them to achieve this.

 

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had good governance systems in place which had identified areas for improvement and there was an ongoing action plan to address these. This involved a wider refurbishment project of the service. Audits were completed by staff including for clinical areas such as people who were prescribed anticoagulants (blood thinning medicines) to ensure appropriate risk assessments were in place, daily walk arounds, care records, and for health and safety. Where outstanding actions were identified, these were added to a wider action plan.

The provider was responsive when we identified areas for improvement as we have highlighted in previous sections of this report. There had been recent changes at the provider-level and an operations manager was in place to support the registered manager in the running of the service. Where we highlighted areas for improvement, the provider sent us evidence.

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 registered manager understood their responsibility of working with partners in order to ensure people could be involved in their local community. We saw several examples where the management team had worked closely with external partners to make the process as seamless as possible. One visiting professional told us, “I think the care and the management are good and I have not had too many issues to deal with related to matters in the home.” A healthcare professional commented, “I felt that the team followed my advice well and were able to provide accurate information…”

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

People were encouraged to participate in improving the service. This was done through a range of methods in order for people to be able to join in a way that suited them and included such as a residents’ and relatives’ evening and a resident council meeting.
 

The management team was in the process of reviewing all care records and we could see that progress was ongoing. They had identified learning from reviewing care records and it was clear that improvements had been made. There was a culture of continuous learning, and the provider actively addressed areas we highlighted and provided us with evidence of completion. There was a service improvement plan in place for smaller and larger improvements to be made to the service, such as in relation to care planning or the physical environment. Where actions required further time due to involvement of external parties such as when replacing fire door magnets, there were clear timelines for completion recorded and we saw where progress was ongoing.

Staff were encouraged by the management team to undertake training in areas they wished to improve, and to share ideas for improvement and innovation.