Ash House

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 requires improvement because the provider was in breach of the legal regulation in relation to good governance. At this assessment we found the service was no longer in breach of that regulation, but further improvements were required. At this assessment the rating has therefore remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 46 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

At our last inspection we found the culture within Ash House had not always promote an open, inclusive and person-centred service. As a result, the provider had taken action to support staff practice to ensure it aligned with their vision and values of ‘delivering exceptional care and support’. At this inspection, we found some improvements had been made and staff described improved communication within the home. One staff member told us, “We have greatly improved since this time last year, there is a lot more being done to get the people we support more active. We are working better as a team, and everyone is pulling together to give the people we support the best life possible.” Another staff member told us, “If anybody wants a hand or somebody to check something, there is always a team leader or another staff member to give you that support. I feel quite supported.” However, some staff felt there were further improvements required to promote good teamwork. When we asked 1 staff member about the culture, they responded, “I think it could be better. I have seen people get frustrated and I have seen frustrations amongst staff, and it can be draining when you sense tension between your colleagues.” We found some processes did not support a shared and inclusive culture and shared accountability. For example, staff worked with people 1 to 1 in their individual living space and had individual handovers relating to the person they were working with that day. This meant there was limited opportunity for staff to come together as a team at the beginning of a shift to cascade shared messages and understand specific challenges their colleagues may be facing.

Feedback from relatives indicated people were not consistently being supported to follow their known interests or try new experiences. Relatives told us events that had previously enhanced the community of the home no longer took place and that inconsistent managerial oversight impacted on people’s quality of life. One relative told us, “New managers will come in with great ideas, but they leave before they are implemented.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. There was long-term inconsistency in the leadership of the home and integrity and openness was not always reflected by senior leaders.

Three managers had been appointed since our last inspection of the service, but all had left after short periods of time. The manager appointed in February 2025 was due to leave during the period of our inspection process. Staff spoke extremely positively about this manager and the deputy manager and described improvements in the service under their leadership. However, staff expressed concern that these improvements would not be sustained due to ongoing inconsistency in the day-to-day leadership of the service. One staff member commented, “I finally felt I had a manager I could go to and now she is leaving. I think ‘how long is the next manager going to last’.” Another member of staff told us, “I think the main problem is management structure. I was very disappointed [name of manager] was leaving after such a short time. I am concerned things are going to go back to the way they were. You need the captain to steer the ship and give clear direction otherwise we are going to be heading for the rocks again.” Staff told us there had not been a consistent or formal approach by the provider in sharing news of the manager’s departure; some staff had only recently become aware.

People, relatives and health and social care professionals expressed concerns about the constant changes in the leadership of the home and how this reflected on the provider. Comments included: “The management changes so regularly, it can’t be true. There is no stability there whatsoever. It has got to be questionable why no manager stays there”, “There is a problem with keeping the manager and discovering why” and “I know they are trying hard but with everything keep changing with the management – they just can’t get anyone to stay.” Relatives told us the manager had informed them they were leaving the day before they left. They had not received any formal communication from the provider prior to that date and had not received any clear or detailed information about the future management of the home. One relative told us, “They have the most precious thing we have (their family member) and sometimes I think they forget that.” The provider’s area manager addressed this following our feedback.

People did not always feel they could speak up and that their voice would be heard.

Some staff told us they felt very confident to speak up and express their views and opinions. One staff member told us they had reported a concern and commented, “There was no quavering, they dealt with it with sensitivity and sorted it. They went back later to check for improvement. Suggestions are listened to, and I would be comfortable to challenge.” Another staff member commented, “I would speak up to managers if anything was wrong. I would go to HR (human resources) and take it further.”

However, this confidence was not shared by all staff. One staff member told us, “There are certain things that are beyond the control of the managers” and gave an example of an issue which had been raised many times but had still not been addressed. Another staff member said, “What is the point about speaking about issues when we feel we are not listened to or we are, but nothing is done anyway.” Minutes of team meetings did not demonstrate they were being used as an opportunity to gather staff feedback or seek their views and opinions.

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. However, we did identify some cultural issues within the service which needed to be addressed.

The majority of staff spoke of a service that promoted equality and diversity and implemented reasonable adjustments to support them in their role. One staff member told us, “It is really promoted, we have people from diverse backgrounds and people from the LGBT community. I feel I can go to management if there is any divide or discrimination between the staff as it could impact on the people we are supporting.”

However, some feedback indicated work was needed to ensure a cohesive workforce that reflected the provider’s policies on inclusion and diversity. The provider’s area manager told us this was an area they were currently focusing on and described some of the processes being implemented. These included an anonymous equality and diversity survey, the introduction of an equality, diversity and inclusion champion and an exercise on the culture in the home. They recognised the importance of this work because, “Without our staff team we havent got a service. The staff team are so important to the services we provide and the quality we provide. It is them interacting with each other and working as a staff team.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance.

The provider had implemented a tiered governance system. Each tier contained essential service level checks, validating the checks of the tier below and escalating issues identified to the tier above where necessary. Staff with delegated responsibility to carry out tier checks had received training to carry out those responsibilities. Managers carried out regular ‘walkarounds’ of the service which were recorded and used to identify day to day issues and recognise good practice within the staff team. The system needed to become embedded to demonstrate how it was improving the culture in the home and people’s lived experiences day to day.

A significant lack of continuity in the management of the home for an extended period of time meant actions identified outside tiered governance checks had not always been completed. For example, the family forum in August 2024 had listed actions to support communication and increase people’s engagement in the community. Relatives told us these had not been actioned. We also identified the management of informally raised concerns needed to improve to ensure they were addressed in accordance with the provider’s policies and procedures and legislative requirements.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Feedback from relatives indicated inconsistency in the management of the service impacted on their ability to work in partnership with the service and the provider. One relative told us, “They have been saying they want suggestions for 2 years. They say they'll do things, it could well be the change of managers, but they don't get done.” Another relative commented, “There have been many many changes. I get angry in some ways because when we ring up, we don’t know who to speak to.”

Healthcare professionals expressed similar concerns. One healthcare professional said, “The management at Ash House has changed frequently which over time has made consistency and continuity problematic.” Another told us, “It has been a journey due to a time of constant changes in managers at every level, but things seemed to have settled down.” A further healthcare professional commented, “With so many changes in the management team some of the information has been lost so there has been a lack of continuity.”

The provider’s area manager recognised work was required to promote partnership working and include people and relatives in developing the service. They told us they planned to involve people and relatives in the recruitment of new staff and to hold further family forums in the service.

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.

The provider had acted to address issues identified at our last inspection. However, some of these improvements needed to become embedded in staff and management practice to ensure consistency in implementation. The long-term lack of consistency of management at the service meant further improvements were required to ensure the model of care was in line with current best practice guidance as set out in ‘Right support, right care, right culture’ and people were experiencing the best life possible. Relatives needed more confidence they were listened to by leaders and that their feedback and suggestions were used in developing and evaluating improvement and innovation initiatives.

The provider was collating ‘celebrating success’ stories to shine a light on good practice and collaboration that had achieved good outcomes for people.