Ashill Lodge Care 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 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 inadequate. At this assessment the rating has changed to requires improvement. This meant the management and Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service remained in breach of the legal regulation in relation to good governance; we could not be assured they had robust systems in place.

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 had a clear shared vision, strategy which was based on transparency, equity, equality and engagement. We found that staff including management could not inform us of all their values, so we were not assured these were embedded within the service and there was no evidence of them being actively communicated through staff meetings or supervisions to be assured staff implemented and followed them. However, the service acknowledged this and had plans to create new values with the involvement from staff on what they feel is important. This was only being discussed at the time of the inspection, so we were unable to assess the effectiveness of it. We will check for improvements at our next inspection.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation and do so with integrity, openness and honesty. We found the service was not open and honest about the use of the what’s app group that was implemented. The service stated this was used to share photos and videos with relatives, although we found evidence that this was not the case. Footage was taken of a person and was not shared with a relative until 4 months after it was recorded and was only shared with the relative at the request of the Care Quality Commission (CQC) due to them being informed via a whistleblower. The service was not open and honest. The relative was asked their opinion on the displayed behaviour in the video and were not informed why the video was taken along with a caption a staff member had recorded and the action the provider took following it.

However, the service conducted unannounced spot checks on the environment frequently and had a registered manager in place who had appropriate skills and experience. The registered manager had recently completed further qualification in health and social care and was currently undertaking a programme with the skills for care to increase their knowledge further.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had a freedom to speak up policy in place. The provider issued staff with an employment survey that gave staff the option of remaining anonymous to ensure they would receive a more accurate reflection of the service and reliable data to review as staff were empowered to speak more freely. There were regular staff meetings and staff informed us they felt confident in raising concerns and what action they would take if they did not feel listened to. A staff member told us, “I am not afraid to speak up and always go to [registered manager] I have a moan; things get done and I move 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. We received positive feedback from staff who felt they were supported well in the service. The provider had measures in place to ensure appropriate support was available for staff to ensure and enable them to carry out their duties. Staff had regular supervisions and there was flexibility in staff attending meetings and this being viable by Microsoft teams, so staff did not have to come into the service on their days off. All staff we spoke with expressed the flexibility of the service and how they have been supported with their own personal circumstances. A staff member told us, “They are really understanding about my personal circumstances, I have time off to attend appointments and make the time up another day.”

The provider did not have clear systems of accountability and good governance. They did not act on the best information about risk or share this securely with others when appropriate. The providers systems continued to fail to identify these areas and drive improvement. At our last inspection we found the provider failed to ensure that people’s rights were respected and aligned with General Data Protection Regulation (GDPR) requirements by not having effective systems in place. People were discussed in a what’s app group that involved staffs own personal devices and the provider could not evidence staff were unable to access that information when they left employment. In addition, we found people were not following the correct modified diets as recommended by healthcare professionals. Safeguarding concerns were not always raised when concerns were identified.

Whilst improvements were noted during this inspection we found continued concerns in these areas. Staff were able to take photos and videos on their own personal devices of people living in the service, some of whom lacked capacity to consent and the service could not be assured the protection of their personal identifiable information. Relatives were not informed that photos and videos were taken on staffs own personal devices when they were asked for consent. We found concerns around the lack of evidence of people following the correct modified diet for all foods they consumed and a shortfall in safeguarding concerns being reported. In addition, on this Inspection we found some risk assessments did not fully assess the risk and they could not evidence all risks were appropriately monitored.

However, the service had improved since the last inspection, and they had implemented and embedded several new systems which had improved the oversight.

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. The registered manager gave several examples of sharing good practice and learning from healthcare professionals that visited the service and speaking with some healthcare professionals they echoed this, 1 healthcare professional told us “Another healthcare professional wanted to move this [person] and [the service] advocated beautifully for this [person]. I was proud of them and it is the type of care that they should be providing. We found a way around it all.”

The service had tried to engage more with the local community but people living in the service were reluctant. The registered manager informed us of trying to bring more of the community to the service and was looking into the dementia café within the local village and see if any people would be interested.

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 and research. We found on this inspection the service was still in breach of historical concerns we identified on the last inspection and these issues still needed to be resolved.

However, we note the service has improved in some areas. Throughout our inspection the registered manager showed us their increase in knowledge by completing further qualifications and participating in programmes to enable them to learn more and lead the service effectively. They informed us of ideas to improve the experience for people and how they would implement it in the service, this would increase the accessibility of the service and ensure it was more dementia friendly. Where we identified concerns throughout the inspection and shared this with the provider, they acknowledged the short falls and informed us how they planned to rectify the issues.