Ashby Lodge Residential Home

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• 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 regulation 17 good governance at the service. We found systems and processes were not established and operated effectively to monitor and improve the quality and safety to the services provided in the carrying on of the registered activity.

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 did not always have a clear shared vision, strategy and culture which was based on transparency and inclusion. This was due to high management turnover in the service with only acting up and temporary managers in post. This had impacted upon the direction and culture of the service as regular feedback, meetings, supervision and appraisals of staff have not been completed. A recent appointed registered manager and acting deputy were in post at the time of our assessment, and with support from the provider’s quality assurance lead, were working towards an action plan to improve the direction and culture within the service.

The provider did not always have consistent leaders who understood the context in which the service delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. Staff told us the presence of temporary managers at the service had impacted upon the service delivery. This was due to managers not always listening or providing regular support, meetings or supervisions to staff. Since the recently appointed registered manager had been in post, staff told us they felt they were receiving regular support from the management team but expressed concerns whether previous high management turnover would persist in the future. Action plans had been put in place and more robust governance systems had been implemented.

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, or share this securely with others when appropriate. We looked at a number of audits for 2025 relating to infection control, health and safety and care plans audits. Not all audits were completed consistently in 2025. However, this was being addressed by the registered manager and more robust systems had been implemented and action plans to address areas of concern at the service.

The provider did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Accidents or incidents had been recorded, but there was no evidence of any referrals, sharing of information with partner agencies as appropriate prior to late June 2025. This had been addressed and referrals to appropriate partner agencies were being made under the new management team to allow for effective collaboration.

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. There were no records of any meetings with people who use the service, relatives or staff. The provider completed incident and accident records but did not complete any analysis of the accident or incidents or refer to appropriate partners to allow for any feedback, learning and actions. However, since the recent appointment of registered manager changes had been made and there was an action plan in place to implement more robust quality assurance processes at the service.