Ashdown Lodge

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 remained unchanged.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 promoted a shared culture and values based on respect, inclusion, transparency, and supporting people`s rights. Their approach focused on creating an environment where people felt comfortable, valued and supported.

We observed staff putting these values into practice, through warm and respectful interactions, taking time to listen and engage with people in a meaningful way.

Staff told us leaders were approachable and supportive in their roles. A staff member told us, “[Name] is extremely approachable-she really cares about us and the residents, and she is always there to help out if needed.”

The provider told us the service had developed a positive reputation within the local community, with most admissions resulting from recommendations through “word of mouth” and rarely any vacancies within the service.

Leaders demonstrated an understanding of the needs of people using the service and had fostered a culture where people and relatives experienced a sense of belonging, and inclusion. A relative described the culture as, “family orientated and welcoming”.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

They were long standing leaders within the service, which provided consistency and familiarity for people, relatives and staff.

The majority of feedback from people, relatives and staff was positive. A relative told us, “[Name] is more than good at her job. She's very professional, she keeps us informed and the girls are friendly.”

Leaders promoted an inclusive culture and valued the different experiences and contributions of staff. This helped create a supportive working environment and contributed to positive relationships between people, relatives and staff within the service. A staff member told us, “I have worked at several other homes, but none have felt as comfortable as it does here.”

The provider promoted a culture where people could raise concerns and expect these to be listened to and acted upon. The service was a small home with an established staff team and close working relationships. While experiences of speaking up varied between individuals, we saw evidence that concerns, suggestions and complaints that were raised were responded to promptly with appropriate and proportionate follow up actions taken by the provider. This helped support a culture where feedback was used to drive improvements within the service.

Feedback from people and relatives was generally positive and they understood how to raise concerns if needed. A person told us, “They are pretty good at listening to us. Whatever we ask for we get, and if we don’t like something we tell them.”

A relative told us, “No I haven’t raised a complaint. But we do know the process if we had to.”

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. The workforce came from a range of ages and experiences and leaders recognised and valued the different skills, perspectives and experiences staff brought to their roles. Leaders supported staff with opportunities for career development and progression which encouraged staff growth, confidence and retention within the service. A staff member told us, “There is very small staff turnover as generally we have all worked here for some time or keep returning to work here which speaks volumes.”

Staff well-being and contributions were recognised through various gestures of appreciation including, paid training opportunities, birthday cards, and Christmas vouchers.

Leaders had arranged equality and diversity training for staff, who used these skills to support a diverse group of people with varying and sometimes complex needs in a respectful and inclusive way. Staff understood the importance of inclusive practice and how this supported positive working relationships, benefiting the vulnerable people they supported. This helped promote a culture where people`s individuality, backgrounds and protected characteristics were respected and valued.

The provider did not always have effective governance systems, clear oversight or robust processes to identify and address areas for improvement. Although systems were in place, these were not always effective in monitoring care related aspects of the service.

For example, the service improvement plan focused mainly on environmental matters and did not sufficiently reflect improvements relating to people's care and support. Care plans did not always contain detailed, personalised information, and information was recorded across both hard copy and electronic systems, which created a risk of inconsistency and reduced effective oversight of people`s care and support needs. In addition, risk assessments were largely task focused and checklist based, without clearly describing how the identified risks should be managed or reduced.

These shortfalls created a potential risk that staff may not always have clear written guidance to support people consistently and that opportunities for continuous improvement may not always be identified promptly. We fed this back to the provider who acknowledged the concerns and had begun reviewing care plans and governance processes to strengthen oversight and improve the quality of records.

We found people`s needs continued to be met in practice, by staff who knew them and their individual needs well. A person told us, “I don’t need a copy of my care plan, and nor do the staff, they know me very well.”

The provider understood the importance of working collaboratively with other services and professionals, so people received coordinated and consistent care and support. Staff maintained regular contact with the GP practice including weekly ward rounds and worked closely with pharmacies and a range of NHS professionals to support and improve people's health outcomes.

The provider also made appropriate referrals to external agencies, including the local authority and CQC when required, demonstrating openness, effective information sharing and partnership working to support people's safety, well-being and protection from harm.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They promoted creative approaches to delivering equality of experience, outcomes and quality of life for people.

The provider worked with healthcare professionals and used their guidance to inform and improve practice, supporting safer and more effective outcomes for people. A relative told us, “Yes, they manage her health needs and they are being met.”

The manager was actively involved in local and provider forums, working collaboratively with peers to share learning and support ongoing improvement and make changes where needed and this was shared with staff to support care practices.