Ashchurch View

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 Good.

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 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There was a positive culture across the service, where equality and diversity were actively promoted. The causes of any workforce inequality were identified, and action was taken to address these. Quality audits and action plans were in place and there was a clear focus on learning and improvement. Staff are aware of the provider’s values and were able to give examples of how these affected their work.

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 did so with integrity, openness and honesty.

Prior to the assessment CQC had received numerous concerns about the leadership style of the registered manager, however, there was no evidence to support these concerns during this assessment. We observed positive interactions between leaders, staff, people and visitors throughout the inspection. Staff feedback indicated leadership had become more visible and communication with the management team had improved as a response to the concerns which had been raised. People, relatives and staff spoke positively about the registered manager. One relative told us, "The [registered] manager is excellent. Can’t think of anything negative. I know any concerns would be acted on." Another relative said staff and management kept them informed and described them as "very alert". Staff described leaders as approachable and told us they felt comfortable discussing concerns and seeking support when needed.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

When concerns were raised, the registered manager investigated sensitively and confidentially, and lessons were shared and acted on. Staff and leaders acted with openness, honesty, and transparency. They challenged each other and held each other to account in a constructive way.

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 registered manager continually reviewed and improved the culture of the organisation in the context of equality, diversity, and inclusion. The registered manager took action to prevent and address bullying and harassment at all levels and for all staff. There was a clear focus on supporting staff with protected characteristics under the Equality Act and those from excluded and marginalised groups.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The governance and oversight of the service was used to develop a service improvement plan for the service. There was a comprehensive system of audits and reviews in place which enabled the registered manager to maintain oversight of quality throughout the service.

The registered manager was actively involved in all aspects of the service and used their practical involvement to review and monitor the delivery of good quality care and support.

However, the audits conducted did not identify the concerns we found about staffing levels during our assessment as they showed staffing levels were within safe levels. Please see the safe and effective staffing quality statement for more details.

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.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. Relatives described positive communication with the service and told us staff worked collaboratively with them to support people's needs. People were supported to access healthcare services when required and referrals were made to external professionals to help ensure people received appropriate care and treatment. People were encouraged to remain connected to their local community through a range of activities and events. Relatives spoke positively about community involvement and described people attending local venues and participating in activities outside the service. Feedback from relatives and staff indicated the service had developed positive relationships with those involved in people's care and support, helping people to maintain connections which were important to them and supporting positive experiences.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff and leaders embed evidence-based best-practice in the organisation. The registered manager encouraged staff to ‘speak up’ with ideas for improvement and innovation and actively invested time to listen and engage with staff. There was a keen sense of trust between leadership and staff.