Ash Cottage

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.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the service 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 the governance of the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. Staff spoke positively about the culture of this service. They said, “The culture and work ethic here is good, we work as a team and there are no problems or arguments. The main thing is we provide exceptional care for people, and this is the focus.” The registered manager spoke of the services core values which are dignity, respect, compassion and genuine person-centred care. A range of policies and procedures were in place to support and guide staff. The registered manager carried out spot checks to ensure appropriate moving and handling, cleaning tasks and nutritional needs were being met. However, we found concerns in these areas.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders did not have the skills, knowledge, experience and credibility to lead effectively. We found concerns relating to the leadership of this service. We found a high number of maintenance and infection prevention and control issues which had been escalated by the deputy and registered manager to leaders on numerous occasions and no action had been taken to address them until we raised this with leaders during our visit. This placed people at risk of harm as the environment was not safe. We saw evidence of staff meetings taking place. However, there was limited evidence of information sharing or lessons learnt being discussed at these meetings. A board was displayed in communal areas for relatives or staff to scan to provide feedback and staff surveys had been completed. However, these were not anonymised so staff may feel they can’t be honest when completing feedback. In addition, staff surveys had not been analysed to identify trends, themes or ways to improve.

The provider and senior leaders completed their own audits; however, concerns found on these audits were not always actioned and we found the same concerns during our visit. Staff praised the registered manager. They said, “The (registered) manager is really supportive and has taken this home (service) to a good place. [Registered manager] is very supportive of staff and very approachable. I feel I can speak to them about anything.” However, concerns were raised about the lack of action when it came to maintenance issues at this service and one staff member said, “I wouldn’t recommend this place (service) to a loved one because there are too many maintenance issues.” The registered manager told us they met with senior managers, managers of other services in the group and the provider regularly to discuss information sharing and continuous learning.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us what the term freedom to speak up meant. They said, “This means not being scared to raise concerns. I am happy to raise concerns if needed.” The registered manager told us openness was promoted by encouraging staff to speak up, question practice and share ideas.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they were treated well. They said, “I am treated well. I haven’t asked but if I needed any adjustments they would be given. One staff member asked not to do 3 long days in a row and we have sorted this.” The registered manager told us reasonable adjustments were based on individual needs including adapted duties, flexible hours, specialist equipment or additional support.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The environment during our site visit was not safe. The kitchen door had no lock on despite kitchen staff reporting this and no action was taken. A new lock was fitted during our visit, however, when we returned on day 2 the kitchen door was unlocked which meant there was still a risk to people. Office doors also had no lock which had not been identified in environmental audits. A range of audits were in place but were not effective at identifying the concerns found during our assessment. The accident and incident audit was not analysing key data such as where people were falling or the time and events leading up to falls. Where audits identified concerns or actions needed, it was not clear whether these actions had been completed or addressed. We were not confident the leaders of this service had thought about people’s specific needs and how this would impact on staffing levels.

Records were not always accurate and a lot of times contradictory. This meant we could not be assured these records would guide staff and keep people safe from harm. Staff told us the management team were knowledgeable and treated all staff well.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. Professionals told us they were not always kept updated or informed with accurate information in relation to people’s healthcare needs. Staff told us people did not attend any local community groups and staff did not take people out into the community. However, the registered manager told us people were encouraged to go into the community, although, we saw no evidence of this.

The service 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 and research. Although we saw evidence of reflective accounts, there was no evidence that lessons had been learnt following incidents and this was more of an account of what happened rather than learning from events. The registered manager implemented a new flash meetings document to include lessons learnt following a local authority visit just before our assessment commenced.

Staff were allocated champions in different roles including nutrition, continence and oral care. However, the staff members we spoke to could not confidently explain what this role entailed or what additional work they did to ensure staff understood this area. When asked what their champion role entailed one staff member said, “Not sure, to keep things stocked up.”