Ashridge Court Care Centre

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.

This service scored 57 (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 told us of their shared vision and culture, but improvement was required to ensure it was embedded throughout the service. The provider was committed about ensuring that people received support based on equality and human rights, and diversity and inclusion. However, the management culture had impacted on the smooth running of the home and on the staff team being able to perform their role in promoting person centred care and meeting people’s health and social needs consistently. The staff team were struggling to perform their role and felt unsupported and not listened to. Staff morale was very low.

The staff understood and supported people’s cultural and spiritual needs. People were treated equally, and their individual needs were met in line with their preferences.

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, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Staff commented that they had found support lacking from the senior management team and at times felt under pressure. One staff member said, “We are not supported or being told we are doing a good job.” The provider was not aware of these concerns and would be talking to all staff to ensure that they feel supported and rebuild their confidence.

The provider took immediate action and changed the management of the home and staff are being supported by a peripatetic manger and other leaders which had already impacted positively on staff who said, “It’s a good change, we can work properly, do our job and feel valued.” On our second and third site visit the changes in staff and care delivery were positive to see. Staff described senior management as being supportive and approachable and always available to answer questions. One staff member said, “I am feeling more valued now than I have done for a while, it’s good to have that support, we are a good team, but we do need a clear leader.”

People and staff did not always feel they could speak up and that their voice would be heard. Relative and staff meetings had been held but not always attended by the registered manager. This meant that actions discussed were not always followed up to reassure people and staff they were being listened to. Supervision meetings were scheduled to take place regularly, but these were inconsistent with some staff having not had a 1 to 1 meeting with a manager for over 5 months. We were also told by staff that in a year they had never met the registered manager in person, and they had never visited the unit they worked on.

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.

The manager told us they promoted workforce equality and diversity. They commented, “We have a diverse range of staff. We treat them all the same and have no preferences. We promote fair recruitment.”

Leaders also told us they celebrated different cultures. Staff did not raise any concerns about workforce equality, diversity and inclusion.

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.

Whilst there were audits and systems in place to govern the oversight of the service, these had not identified and/or addressed some of the issues we found on inspection. For example,

staff training and supervision was not fully up to date and showed gaps. Training has now been booked and staff supervisions being undertaken as a priority. Not all accidents and incidents and lessons learned were documented with an outcome or actions taken. This put people at avoidable risk of repeated accidents and incidents within the service. We also found that certain areas of the service, such as clinical areas and communal bathrooms were not clean and were cluttered. There were also some documents mislabelled and in the wrong persons file which could have caused confusion. These were immediately actioned and risk was therefore mitigated.

The senior management team had identified some of these shortcomings 2 weeks before the site visits and had produced an action plan to address the issues.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff engaged effectively with external professionals and followed their recommendations.

People were supported to access medical services when needed, and staff worked closely with GPs, specialist nurses and other healthcare professionals to ensure people’s health needs were met promptly. Information was shared appropriately, enabling external professionals to understand people’s needs and provide consistent care.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The management team spoke passionately about the need for continuous learning to drive improvements for the service. They shared their plans to continue improving the service. However, their systems and processes were not always operated effectively to support these plans. For example, when we discussed incidents and accidents and lessons learnt, we found the learning was not as robust as it could have been and lessons learnt were not taken forward effectively. For example, pain management and medicines at end of life care. Whilst we did identify shortfalls during this assessment, the provider was responsive and took action to address key areas of improvement.