Ash Tree

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.  At our last assessment we rated this key question good. At this assessment, the rating remains 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 68 (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. Staff spoke positively about their overall experience working at the service. Staff frequently referred to positive teamwork and there was a clear set of values focusing on supporting people as individuals to ensure they were at the centre of their care. They told us they would recommend it as a place to work.

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. Staff told us the registered manager was approachable and supportive. A staff member told us, " Management are really good. They will look at documentation or practices and if something is not being done right, they will raise with staff and explain why things need to change. They are good at monitoring things, particularly [registered manager].”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. We saw people were comfortable sharing their views and expressing their needs and wishes with staff. Staff told us they were able to voice their opinions and make suggestions in staff meetings and supervisions and directly with the registered manager. A staff member told us, “They are approachable; if I had any concerns I would raise with [registered manager]. I have confidence they would listen and sort it out.”

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 their diversity and culture was respected within a culture of positive teamworking. The registered manager encouraged people to share information about and discuss their cultures to support understanding and respect for diversity within the staff team.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act in a timely way on the best information about risk, performance and outcomes. For example, they did not always act in a timely way to address environmental shortfalls we found during this inspection. They did not provide sufficient oversight or support for the service to ensure improvements were made in a timely manner. Staff told us the registered manager was committed, approachable and supportive. The registered manager completed audits and checks, though systems and processes required further development to provide effective analysis and monitoring. The registered manager demonstrated they had good oversight of the care provided. The service was registered prior to right support, right care, right culture guidance. While the environment had been adapted to support people’s needs, further adaptations were needed. People had life enhancing opportunities through personalised care.

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 closely with external agencies and the local community to ensure people could access the services they needed and had equal access to facilities and opportunities in the local community.

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 as they had not maintained effective oversight and support for the service. The provider was slow in making improvements to the environment as we have previously mentioned in other areas of this report. The registered manager was committed to providing a safe, good service for people.