Ashlett Dale Rest Home

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 has changed to 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 provider was in breach of the legal regulation relating to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People made positive comments about the staff and management. Relatives said the managers were approachable and welcoming. Feedback from staff and external health care professionals was also positive.

The registered manager told us they were a member of a registered managers forum, which provided a platform for discussion and sharing of practice ideas. The registered manager also received CQC updates.

The registered manager had a deputy manager who was confident in being able to run the home in the registered manager’s absence.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Systems and processes to assess, monitor and improve the quality and safety of the service had not been established and operated effectively. Statutory notifications had not always been sent to CQC when required. These were submitted retrospectively.

During our inspection, we identified a number of issues in relation to the governance of the service. For example, care plans and risk assessments did not always contain clear guidance for staff. Follow up actions were not always recorded or monitored effectively. Systems and procedures for recruiting new staff were not robust. Staff competency checks did not always take place or were not recorded. We found 2 breaches of the regulations in the areas of staffing and governance.

The registered manager did not have a service improvement plan to demonstrate knowledge and understanding of current issues and how these were reviewed and acted upon in a timely manner and used to drive improvement. We could not be assured care records were robust enough to support the delivery of consistent and appropriate care.

During our visits, the registered manager was responsive to issues we identified. Following the inspection, the registered manager sent us copies of quality monitoring tools they were planning to implement, including for example a resident’s survey, and weekly task checklists.

Throughout the inspection, we observed some examples of effective care practices. We saw evidence of ongoing improvements being made to the premises.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.