Ashington Gardens

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.

Under the previous registration 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 71 (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. The registered manager was new in post although had worked for the provider for several years. They were aware of recent challenges that had been presented following a safeguarding investigation and were keen to learn and develop the service for the better. Much of the registered manager’s vision for the future of the service focussed on staff and staffing team. The registered manager said, “In 12 months’ time I want to have a full staff team with no agency. I want staff to feel confident in using the new digital system.” Moving to a fully computerised system for recording and storing all information about the service had begun and had been effective so far. Staff told us that things had changed for the better at the service in recent months. A staff member said, “I think all of the issues flagged have been addressed.”

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. Staff told us that the new registered manager and their wider management team were approachable and available for advice and support when needed, despite the concerns also raised relating to staff wellbeing. An on-call rota, shared between managers was in place so staff could reach out for help at any time of the day or night as needed. A staff member told us, “Yes, the (registered) manager is generally approachable and supportive. They are willing to listen to us and offer guidance.” Relatives also told us that they found the registered manager approachable and that communication worked well.

The registered manager fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they had a voice at the home. The home was relatively small with a small staff and management team and so there were daily opportunities for staff to talk with the registered manager or others in charge if they needed to. There were home staff meetings every Tuesday and staff told us this was an opportunity to raise issues and that the management team always responded. A staff member said, “Managers listen and respond to issues raised. Good listeners and do what they can to support us.” If staff were unable to make the Tuesday meetings, including night staff, they could message in questions which would then be discussed at the meeting and fed back. More formal supervision meetings were held with staff every 6 weeks which were documented.

The registered manager valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. People and staff were respected by their peers regardless of their various protected characteristics and differences. Equality and diversity policies were in place and regularly reviewed. The registered manager adopted an inclusive approach and had created a culture at the home of togetherness, where staff felt comfortable coming to work. A member of staff said, “We support each other within the workplace through an inclusive approach, respecting individuals and their differences.”

The registered manager 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. Despite being new in post, the registered manager knew the service well and maintained oversight of all systems and processes. A senior member of staff was responsible for data collection. This covered all aspects of service delivery including for example, training, accidents and incidents, safeguarding and medicine errors and competency checks. The data was presented in spreadsheets aligned to the CQC quality statements which was innovative and effective as it immediately highlighted areas where the service was performing well as well as areas where improvement were needed. Full audits were done every term to align with when people were most at the home. More frequent auditing was completed in some areas for example, medicines and accidents. The registered manager had created a governance tracker and assigned a red, amber, green tagging system to every issue. Red for immediate action, amber for action within a few days and green no action required. This was an effective way of maintaining oversight and tracking issues. Also, key areas from the registered manager’s reports could be shared with all staff to ensure actions were completed.The registered manager was aware of their responsibilities under the duty of candour. Legally, registered managers must inform the CQC and the Local Authority of certain events that happen at their services. This obligation had been met.

The provider had not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They had not always shared information and learning with partners or collaborate for improvement. Partnership working had significantly improved following a safeguarding investigation earlier this year and the appointment of the new registered manager. Feedback from professionals varied. A more recent example of where support was required for a person with a new medical diagnosis was managed well resulting in a professional telling us, “A specialist nurse has expressed how pleased they are with the way the team is managing (person’s name and condition) care.” However, another professional said, “On occasions when I have required information, it has felt as though we have had to repeatedly follow up for updates and documentation. While the staff are approachable and helpful, more timely responses to emails and requests for information would strengthen communication and improve collaborative working.” The new registered manager acknowledged the importance of working together with other professionals to achieve the best outcomes for people. However, time was needed for these working relationships to fully embed.

The registered manager 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. The registered manager had only been in post for a few weeks but knew the service well and knew the people supported and their individual needs well. They acknowledged recent challenges faced by the home and were committed to improving the service and establishing positive relationships with other professionals. The registered manager had formed such a relationship with the local authority and they worked together for the benefit of the people supported. The registered manager sometimes attended the local forums created for managers to share experiences and learn from other managers where things had gone well or in some cases where learning had resulted.