Ashton Manor Nursing 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 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 regulation in relation to good governance.

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, 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.

We received positive feedback about the service. Relatives told us, “Everyone knows us so it feels like a family” and “The staff are approachable, hard-working, friendly and genuinely care. The home is well run and well led.”

The registered manager had a clear vision for the service and knew the type of staff they wished working for them. They told us, “The main thing I look for is that they are caring and trusting and they give people choices. From a manager point of view, I need to trust the staff and the residents need to trust the staff too. Not everybody is made for care. I look for honesty because I cannot safeguard people 24 hours a day.”

Staff enjoyed working at the service. We received numerous encouraging comments from staff too, with them commenting, “I am proud to work here. I feel like we are family to them (people)”, “It’s good here. We have a strong team. Everyone always offers to help and we foster a nice environment for the residents”, “I like working here. We have a balanced workload and there’s enough staff” and “I enjoy working here. I am able to give enough time to each resident and can always ask my colleagues if I needed any help.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

Leadership was not always effective in ensuring people remained at the centre of the service as we found shortfalls during our visit in both the care provided and the living environment which had not been identified by management. This indicated inconsistent oversight by the registered manager and senior staff. It also reflected senior staff did not always check to ensure staff provided care delivered in a way that consistently suited people or reflected their individualised wishes or needs.

Additionally, despite CCTV surveillance being used in the service, the registered provider and registered manager had failed to ensure they met the requirements of GDPR and Data Protection Act 2018 in notifying people and visitors of this. Following our visit, the registered manager sent us evidence of new signage to be placed in the reception area.

However, people and relatives felt the service was well managed as we received the following comments. “Management is always around. I love how the place is run. I don’t have any concerns and would recommend Ashton Manor to others”, “Management have got the level of care to a high level”, “I can join [person] on Sundays for a roast lunch which is nice” and “I cannot speak highly enough of Ashton Manor and its staff and management.”

The registered manager understood when to raise and submit a notification to CQC. This included when a person had fallen resulting in an injury or where a safeguarding concern had been identified.

The registered manager understood the importance of recruiting good staff to ensure there was a positive culture within the service. They told us, “You can train the skills, but not what people (staff) feel inside. I am looking for genuine compassion. We have champions in certainly areas and we were finalists in the Surrey Care Awards.” Staff felt supported and told us, “I feel supported to keep learning and developing. There’s always training available”, “I am happy with management and have no concerns.” “I don’t have any complaints with management and I don’t have any concerns regarding any staff.”

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

Staff felt confident to speak up. Staff said, “We’re encouraged to share new ideas”, “I will alert the nurse if I notice any changes in a resident. I feel confident to speak up if needed and management always listen” and “I am happy to speak up if I need to.”

Relatives also said they would speak up if they felt they needed to. One relative told us, “I don’t have any concerns.”

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.

The provider demonstrated diversity in their workforce as a proportion of their staff were on sponsorship from overseas. The registered manager told us, “We make sure everyone has access to the same things and they are treated fairly. We follow a specific criteria which we apply to everyone. We run an award scheme where colleagues can recommend or nominate each other, and we run team building days.” A staff member said, “All of them support me, especially our manager. She helps, she’s good.”

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

A range of audits were carried out across the service by both senior management and the home management. The registered manager told us, “The nurses do medication and care plans. I do the environment and finance and my deputy does other audits. I have oversight of all the audits carried out however and I will check and see if any actions have been set.” She went on to say, “Each month I submit a monthly dashboard to the director and they will come back to me with any questions. Our new system gives us much more autonomy to follow up on things ourselves.”

Despite this, we have reported on a significant number of issues which were not identified through the governance systems. This included staff deployment, maintenance issues, risks not being consistently well managed, poor infection control practices, a lack of individualised care and inconsistent documentation.

Our review of completed audits demonstrated shortfalls had not always been picked up. For example, an infection control audit stated clean linen was stored free from inappropriate items. However, we had seen clean linen being stored with a hair dryer, stock of cardboard urine bottles, jugs, pots and a large pile of communal net knickers (used for fixating incontinence pads) in various sizes.

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 had good links with health and social care professionals as well as the local community. The registered manager told us, “I am part of the registered manager’s forum, although it is just about to disband. I belong to Skills for Care, the Surrey Care Association and also the Hampshire one too. We provide placements for nurses and nursing associates for a wide area and also provide placements for Level 3 HSC students and chef students. The local schools come in and the children will sing to people. In addition to the GP, we have links with occupational therapy, tissue viability, community mental health team and the speech and language therapy team.”

The service worked in collaboration with the local community. The registered manager told us, “We offer free fish and chips to the elderly community once a week. Sometimes no one will come, but on other occasions we may have up to 6 people.” A relative told us, “That’s how I first heard about Ashton Manor. I brought [family member] here on a Friday before he became a resident where they do fish and chips for anyone over the age of 65 and they don’t charge you.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Although the registered manager was keen to improve the service for both people and staff they had failed to identified areas requiring improvements which included in both the care delivery and the environment. It was only when we alerted them to the shortfalls in the service that they took action. This included signage for the CCTV surveillance and assessing people individually for their use of a plastic beaker. Additionally, there were still further shortfalls that needed to be addressed. This demonstrated the registered manager was not always identifying problems on their own or consistently, self-evaluating and learning.

However, larger scale changes were taking place. We had noticed the conservatory area was very warm and not the best layout for people to be able to integrate and socialise together. Following our visit, works started to create a better space for people. The registered manager told us, “For years we’ve had problems with the conservatory and building work is about to take place to open up the dining and lounge areas.” They also added, “We have just built a new laundry room and we relocated the hairdressers.” Additionally, they also considered the comfort of their staff, telling us, “We used to have a small staff room, but we gave over a larger room to the staff so they have somewhere comfortable to take their breaks.”

The registered manager wished to start inviting people from the local community into their service. They told us, “Quite often for example, the person being placed here is being done so by a spouse who is also elderly. I would like to offer a day centre type of service for these people where they can come and spend time here.”

Where we identified shortfalls or areas for improvement, the registered manager was responsive and open to learning and changing practices for the benefit of people.