Ash View

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 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 service was in breach of legal regulation in relation to 17, good governance. This means the provider has failed to operate effective systems and processes to assess, monitor and improve the quality and safety 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 service culture was not always consistent. Whilst some staff described a supportive and caring environment and spoke positively about the relationships they had built with people, feedback from people using the service highlighted concerns regarding the high use of agency staff, communication, missed activities and a lack of responsiveness to feedback. These concerns indicated that a shared vision and person-centred culture were not always consistently embedded across the service, resulting in variability in people's experiences of care and support.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

There was evidence of improvement activity however several themes remained consistent including medication safety, safeguarding concerns, training compliance, high agency usage and the timely completion of event investigations. While improvement initiatives were ongoing and leaders had identified actions to address areas of concern, inspection findings did not provide sufficient assurance that these improvements were consistently embedded or would be sustained over time.

The provider had not ensured effective leadership and oversight of the service. During the inspection, the service level manager was unable to demonstrate sufficient knowledge of key operational and safeguarding processes, including identifying the safeguarding lead, and provided inaccurate information regarding people’s care and support arrangements. This indicated weaknesses in management oversight and reduced assurance that risks were being effectively identified, monitored and managed.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a Freedom to Speak Up policy in place, and staff were aware of how to access and use it. Staff understood how to raise concerns.

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 managers were approachable and took account of their individual circumstances. Leaders demonstrated a willingness to make reasonable adjustments and work with staff to meet their individual needs, helping to create a supportive working environment. Staff spoke positively about the support they received from managers and felt able to be themselves at work.

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.

Governance systems were not consistently effective in monitoring the quality and safety of the service. Although managers told us agency staff were subject to pre-employment checks before working within the service, feedback from people using the service, relatives and staff identified recurring concerns regarding the competency, communication and conduct of some agency staff. People reported inconsistent experiences of care and support, including agency staff not introducing themselves, not wearing identification and not always communicating effectively. We also identified medicines incidents involving agency staff. These findings indicated that oversight arrangements were not sufficiently robust to provide assurance that all staff deployed within the service had the skills, knowledge and behaviours required to meet people’s needs safely and consistently.

Governance and oversight systems were not always effective. For example, electronic call monitoring records identified a high number of unlogged and incompletely logged calls, and leaders were unable to verify whether all planned visits had taken place due to a lack of alternative records. This meant the provider could not consistently assure itself that people were receiving their commissioned support safely, as planned, or use this information effectively to drive improvement and service sustainability.

Managers told us they completed spot checks of people’s bedrooms to monitor the quality, safety and condition of the living environment. However, it was not clear how frequently these checks were expected to be completed, and records did not provide assurance that they were consistently documented. Following the inspection, the provider submitted a sample of spot checks covering a four-week period; however, we were unable to determine whether this reflected ongoing practice or effective management oversight over a longer period.

The provider worked in partnership with a range of external organisations and community resources to support people’s health, wellbeing and inclusion. Records demonstrated liaison with healthcare professionals, local authorities and housing providers, and people were supported to maintain links with their local communities through activities, social opportunities and community facilities.

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.

However, the provider had a range of recognised learning and development opportunities. Staff were supported to access accredited qualifications in health and social care and leadership. New staff completed a structured learning journey aligned to the Care Certificate, enabling them to achieve the Care Certificate within their first 12 weeks of employment.