Ash House

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.

This is the first assessment for this newly registered service. This key question has been rated 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 provider was in breach of the legal regulation in relation to the governance of 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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider’s shared direction and culture were not yet fully embedded at the time of inspection. Although staff understood the service’s values, these were not always consistently reflected in practice. We found learning from incidents and professional guidance was not always acted on or shared consistently, and oversight arrangements were still developing. As the registered manager had only recently increased their presence at the service, these improvements had not yet been fully established.

The registered manager told us they were working to strengthen a shared direction and culture through governance meetings and day‑to‑day leadership.

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. Leaders did not always have the skills, knowledge and experience to lead effectively.

The registered manager told us they had been promoted into the role a couple of months ago and, until recently, had been supporting another service alongside their responsibilities at this service. As a result, we identified gaps in leadership oversight and assurance, as outlined in our inspection report.

Leaders did not always identify or act on issues promptly. For example, there were delays in escalating incidents, inconsistent follow‑up of professional guidance, and limited evidence that learning from concerns was consistently embedded into practice. This reduced assurance that risks were consistently identified, managed and addressed.

At the time of inspection, the registered manager was working full time at the service, which had increased their visibility and availability to staff. However, as this was a recent change, improvements to leadership oversight and ways of working were still developing and had not yet been fully established.

Staff told us the registered manager was approachable and that they felt able to raise concerns or seek guidance when needed.

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

Staff told us they felt able to raise concerns and seek advice when needed. They said they could speak openly about issues affecting their work and felt listened to when they did. One staff member told us, “I feel confident to speak up.”

There were processes in place to support speaking up, including opportunities to raise concerns through supervision and governance meetings. These arrangements helped support an open approach to raising issues.

There was a whistleblowing policy in place and staff were aware of this and the procedures they needed to follow.

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 told us they were treated fairly and respectfully in their roles. One staff member told us, “I have found it to be a very positive place to work.”

Policies and procedures were in place to support equality and prevent discrimination. Staff were aware of the importance of treating colleagues fairly and respectfully, and the registered manager described being mindful of staff needs and making reasonable adjustments where required.

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

The service had governance systems in place to monitor the quality and safety of care, including the use of audits. However, these systems were not always effective in driving improvement or providing assurance.

Records indicated a range of audits were completed, including audits of care planning, daily records, medicines management, health monitoring, and the service environment. While audits identified areas for improvement, actions were not always followed up or completed, and similar issues were identified again in subsequent audits.

For example, audits repeatedly identified concerns with the quality of daily records, with no clear evidence of improvement. Audits also highlighted out‑of‑range medication fridge temperatures, but there was limited evidence of action taken or monitoring to ensure the issue was resolved. This showed that actions identified through audits did not always lead to sustained improvements in practice.

We also saw governance meeting records were largely repetitive, with only minor changes noted between meetings, which limited assurance that issues were being reviewed effectively or that learning was driving change.

Although action plans were in place, there was limited evidence that actions identified through audits were consistently tracked to completion or reviewed to ensure improvements had been embedded. This reduced assurance that governance systems were effective in identifying risks early and preventing recurrence.

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.

Staff and leaders understood their responsibility to work in partnership with external agencies to support people’s safety and wellbeing.

The service worked with the local authority when concerns were identified. Information was shared appropriately, and leaders were open and transparent during safeguarding enquiries. This demonstrated effective partnership working to support oversight and protect people from harm.

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. They did not always actively contribute to safe, effective practice and research.

The service had systems in place to support learning and improvement; however, these were not consistently effective.

Learning from incidents, audits, and governance processes was not always used effectively to drive sustained improvement. We saw repeated issues, including poor recording in daily notes, continued to be identified through audits, and there was limited evidence that actions taken had resulted in lasting improvements in practice.

While actions were identified following audits and incidents, these were not consistently reviewed or evaluated to confirm they had led to positive change.

We did not find evidence of innovation or proactive improvement, and learning was not routinely shared to improve outcomes. As a result, opportunities for learning and improvement were missed.