Ashgrove Care Home - London

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.

The last rating for this key question was requires improvement. At this assessment the rating has remained 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.

We identified breaches of legal regulations relating good governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We identified some practices which were not consistent with the organisation’s culture and values. These included staff not respecting people’s choices or meeting their needs. Some people told us they were not happy with the service in general. We shared these concerns with the management team in order for them to investigate and respond to this.

The provider had values based on the principles of good care. Most people using the service and their relatives felt there was good quality care which met their needs.. Their comments included, “They seem to be pretty good”, “Everyone seems happy, staff as well” and “I would recommend the service, you would not find a better place.”

Staff told us they felt there was a positive and inclusive culture. They all felt improvements had been made by the registered manager. Their comments included, “The manager is good and everyone is [treated as an] equal”, “Things are done fairly and that is much better now” and “I really like working with the residents, they are lovely.”

The provider employed capable and inclusive leaders. The registered manager was suitably qualified and experienced. They were a registered nurse and had management in care qualifications. People using the service, relatives and staff told us managers were visible and supportive. Their comments included, “[Registered manager] has an open-door policy”, “[Registered manager] is brilliant and will always have a chat” and “There are meetings and [registered manager] is quite open with us.”

The provider had systems to enable staff to speak up and share concerns. Staff had training to understand about reporting concerns and there were clear procedures. Staff felt they were able to discuss issues with the management team and they were listened to. Staff told us they knew who to contact if they felt local managers had not addressed any concerns they raised. Comments from staff included, “I get a lot of support to raise issues” and “I feel I am not judged, and managers listen to me.”

The provider had systems for supporting workforce equality and diversity. They had a range of policies and procedures which reflected legislation and good practice for supporting employees. Staff told us their individual needs were met. For example, staff with caring responsibilities told us they were able to work hours which suited their needs.

At our last assessment, we found that systems and processes for monitoring and improving the quality of the service had not always been effective. At this assessment we found this was still the case.

The provider had identified some areas where improvements were needed before our assessment. However, they had not implemented the necessary changes to address these .

We identified improvements were needed with records. These were not always complete or detailed enough. In particular assessments, care planning and risk management plans.

Systems for monitoring and mitigating risk within the environment were not always effective. Whilst the provider had audits and checks, these had not identified some hazards or where improvements were needed.

The provider’s systems for monitoring and improving the quality of care had not always been effective. We observed task-based care which meant that some people experienced a poor service. However, staff reported that there was a more supportive culture and improved training.

The provider also had a range of different audits and checks which included asking stakeholders for feedback. Following our visit to the service, the provider created an action plan which set out how they intended to address the areas which needed to be improved.

Whilst we found that the provider was proactive in responding to our feedback and had made some improvements since the last assessment, there were continued areas of concern relating to records, systems and care provision which showed improvements were needed in relation to the governance of the service.

Staff and managers worked in partnership with other organisations and professionals. The management team had regular meetings with the local commissioners to discuss and review the service. The registered manager liaised with a network of other managers within the organisation and other local care homes to discuss best practice and learn from one another. External professionals reported staff worked closely with them in identifying and meeting people’s healthcare needs.

The provider had systems for learning and improvements. These had been effective in some areas and staff told us positive changes had been made. However, further improvements were needed to make sure people always experienced good quality and safe care. We discussed our initial findings with the registered manager, and they developed an action plan which outlined how improvements would be made. This included additional training for staff.

The provider had not always introduced innovative best practice. The provider had systems to ensure people were not discriminated against and to challenge any discriminatory practice, although they did not always think of innovative ways to actively promote inclusive environments for everyone.