Ashdale

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 remained 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.

The provider’s core values were communicated to staff during induction and reinforced through ongoing training updates. These values were also made accessible to people, their relatives, and external professionals via the provider’s website. Staff demonstrated a clear awareness of these values and reported feeling well supported by the management team.

Staff expressed job satisfaction and highlighted a strong sense of teamwork within the service, with a collective commitment to achieving the best outcomes for the people they supported. One member of staff remarked, “I enjoy coming to work, the team are great and I feel proud working here”.

The culture within the service was open and transparent, with both people and staff feeling comfortable raising concerns. The registered manager and team leaders were consistently visible and approachable, fostering an environment of accessibility and support.

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 registered manager embodied the values of the organisation and created a compassionate and caring culture which valued staff. The management team had skilfully supported staff through a period of significant change which had led to improved outcomes for people. Staff praised the registered manager and leaders and found them to be approachable, responsive, and supportive. A member of staff commented, “We have had some challenges recently and management have been really supportive”.

The provider actively promoted a positive and open culture in which people felt empowered to voice their concerns and be confident that their feedback would be listened to and acted upon.

Staff were equipped with comprehensive information on how to raise concerns, which was embedded within the provider’s electronic communication platforms, ensuring easy access at all times. Feedback from staff demonstrated a clear understanding of the established processes for raising concerns and expressed confidence in the ability to do so anonymously if required.

All staff had access to the provider’s whistleblowing policy and procedures, which outlined the steps for reporting concerns in a protected and confidential manner. Information regarding whistleblowing was prominently displayed on noticeboards throughout the service, ensuring visibility and reinforcing the provider’s commitment to transparency and accountability.

These measures collectively contributed to an environment where staff felt supported to raise issues without fear of reprisal, thereby underpinning the service’s commitment to continuous improvement and safeguarding.

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’s recruitment procedures ensured staff were treated equitably and inclusively. Staff told us they felt respected and valued by leaders. A member of staff commented, "I have had some issues personally and management has helped me through it”.

The provider had clearly defined responsibilities, roles, and systems of accountability, supported by robust governance structures. These frameworks were effectively utilised to manage and deliver high-quality, sustainable care, treatment, and support. The provider based decision-making on accurate and timely information regarding risk, performance, and outcomes, ensuring relevant data was shared securely with appropriate stakeholders when necessary.

The service operated multiple governance systems to maintain oversight and continuous improvement. Various members of staff were assigned responsibility for conducting a range of audits at different intervals. Some audits were performed weekly, while others were completed monthly to ensure comprehensive monitoring across key areas. The registered manager conducted monthly audits in particular areas including medicines management, financial processes, and care plan reviews. Meanwhile, staff carried out weekly checks focused on fire safety, infection prevention and control measures.

The provider ensured statutory notifications were submitted to the Care Quality Commission (CQC) appropriately and within required timeframes. The registered manager demonstrated a thorough understanding of their regulatory responsibilities within a highly regulated environment.

In addition, a regional operations manager regularly visited the service to perform independent compliance audits. These visits contributed to the ongoing monitoring of quality and safety, allowing for the early identification of areas requiring development and the implementation of targeted action plans to address any concerns.

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 provider worked in partnership with other agencies involved in people’s care which helped ensure they received a consistent and effective service. Care records included information and guidance from local authority commissioners, learning disability services and health staff.

The service demonstrated a strong commitment to continuous learning, development, and improvement. Leaders encouraged a culture where staff were confident to share ideas and reflect on practice to enhance the quality of care.

The team worked together to identify simple yet effective ways to improve people’s daily experiences and promote equality, inclusion, and wellbeing. For example, they reviewed communication methods to make information more accessible, introduced visual prompts to support independence, and adapted activity planning to better reflect individual interests.

The service contributed to safe and evidence-based practice by reviewing incidents and feedback regularly, ensuring lessons were learned and improvements were made. Staff meetings and supervision sessions were used to discuss best practice and identify training needs.

The provider also took proactive steps to strengthen health and safety measures. This included reviewing risk assessments, improving record-keeping systems, and ensuring all staff received up-to-date training in areas such as first aid, infection prevention, and fire safety. As a result, there were clear improvements in staff confidence, monitoring processes, and overall workplace safety.