Ashley Lodge Care 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.

This is the first assessment for this newly registered service. This key question has been rated 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 told us they knew who the registered manager was and described them as “good” and “very good.” One person said, “[Registered manager] passes by quite often and if I see her, I will call her and say can I speak to you. I never have any difficulty in speaking to her if I need to.”

Staff told us the registered manager was visible, approachable, and supportive. One staff member said, “The management are mainly with us all the time. If we are doing something and we need help they will be there.”

Regular staff meetings took place, and staff told us they were encouraged to speak up with thoughts and ideas. We saw minutes of staff meetings. Staff were encouraged to develop professionally, such as ‘champion roles’ within the service. One staff member said, “[Registered manager has offered me roles endlessly, but it hasn’t fitted in with my lifestyle so I’ve turned them down. But the staff here are always offered development opportunities.”

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 had the skills, knowledge, and experience to perform their role. They were aware of their responsibilities, and they were open and transparent throughout the inspection process. The management team as a whole were receptive to our feedback and where able, made immediate changes. They led by example, were visible and approachable, and people, relatives and staff all spoke highly of them. All the relatives we spoke with knew who the registered manager was and all spoke highly of her and the staff team who were caring for their relatives. One person’s relative told us, “[Registered manager] is always walking around the home interacting with residents and relatives. I would recommend Ashley Lodge because they do what it says on the tin and residents are looked after.”

One staff member said, “[Registered manager] has been doing the job for a while, so she knows her stuff. [Deputy manager] is on it clinically. Registered manager has a lot of knowledge and empathy. This home is very personal to her; her residents are her family and that does come through.” The registered manager told us, “I take care of people who work for me, so that they can provide good care. I’m proud of my care home.”

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

All staff we spoke with knew how to raise concerns. There was a whistleblowing policy in place. Staff told us they were confident if they whistle blew, they would be taken seriously. The registered manager had an open-door policy and staff told us they felt comfortable speaking with them. One staff member said, “I know where to find the whistleblowing information if I need it. There are things up in the staff room about speaking 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.

There was a diverse workforce in post. Staff from overseas told us they felt included at all times. One staff member said, “We have a multicultural team. I feel a sense of closeness, and it makes me feel at home. I love learning about the cultures of my colleagues. The other staff have never made us feel unwelcome here.”

Staff were given opportunities to provide feedback through surveys and a suggestion box as well as during staff meetings and supervisions.

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.

There was a range of audits carried out across the service including spot checks of staff during the day and overnight. When issues were noted, action plans were created with clear recorded information on who was responsible for acting on them. Processes for reporting, investigating, and learning from incidents were effective and records showed learning was shared with staff. There was management oversight of areas of risk and people’s health and wellbeing was monitored.

Although some of the issues we noted had not been identified during the provider’s audit processes, following the on-site inspection activity, the registered manager updated us with actions taken following our feedback. The provider maintained an improvement plan to track improvements and progress, and we saw issues we raised had been added to the plan.

The registered manager understood their responsibilities and had systems in place to report appropriately to CQC.

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 worked effectively with other health professionals and organisations. The service was well known in the local community and had developed links with other local providers and schools. Community links were maintained through afternoon tea events and local initiatives.

The provider 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.

Lessons learned from incidents and complaints were shared in meetings, and audits informed action plans. One staff member said, “[Registered manager] has a meeting everyday with every head of department member. She’s forever checking everything. She does a walkaround. She has regular meetings with the staff, and she makes sure she gets feedback. She’s forever speaking with the relatives. She values any feedback and she listens.”