During an assessment under our new approach
Ash view operates an extra care model which promoted independence and choice. People lived in self-contained flats and were able to independently manage access to their homes. At the time of our inspection, there were 48 people living at Ash View. The assessment started on 3 September and concluded on the 21 September. We found a breach of regulation relating 17, good governance.
The high use of agency staff was a recurring theme throughout the inspection. People, relatives and permanent staff raised concerns about inconsistency in care delivery, communication difficulties and a lack of familiarity with people’s individual needs and preferences. Some people told us agency staff did not always communicate respectfully, introduce themselves appropriately or provide the same quality of support as permanent staff. These concerns impacted people’s experiences of care and continuity of support.
Care planning and risk assessment processes were established, and there was evidence of partnership working with healthcare professionals and other agencies to support people’s health and wellbeing. However, records were not always consistent, complete or sufficiently detailed. Important information regarding people’s routines, communication needs and support preferences was not always clearly documented or accessible, and some care records did not fully reflect care provided in practice.
The provider’s governance and oversight arrangements were not consistently effective. We identified concerns across several areas including medicines management, safeguarding oversight, training compliance, care records, handovers, infection prevention and control, call monitoring and monitoring of agency staff. Whilst audits and monitoring systems were in place, they had not consistently identified or addressed recurring issues, resulting in repeated concerns and limited evidence of sustained improvement.
Staff generally described managers as approachable and supportive, particularly regarding staff wellbeing. However, governance systems were not sufficiently robust to provide assurance that risks were consistently identified, monitored and addressed. Overall, whilst there was evidence of caring practice and positive outcomes for some people, improvements were required to strengthen leadership oversight, consistency of care, record keeping, workforce management and quality assurance systems to ensure people consistently received safe, effective, responsive and person-centred care.