Ashton Court Residential Home

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 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. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service. 

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. The provider’s values of caring, equality, respect, kindness, choice and listening, were not always upheld. Staff and leaders could not explain what the provider’s values were and therefore were not part of a shared culture. People were not always included in decisions about their care and their independence was not always promoted.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity and openness. Leaders had not always supported staff to deliver safe and effective care which met people’s needs and improved their outcomes. Staff and leaders had not consistently investigated and reported concerns to appropriate external bodies to ensure openness and transparency. We found concerns which should have been reported to the local safeguarding adults service and the CQC. Members of the management team were unsure about issues within the home. For example, 1 member of the management team took a lead on accidents and incidents but other members of the team were not aware of the process or what the current trends and patterns were.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistle blowing policy in place and staff felt supported to raise concerns. However, we identified concerns which had not been reported to appropriate bodies.

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. All staff completed training in equality and diversity. Staff told us they felt supported and could voice their opinions. Systems were in place to support staff out of office hours and at a weekend. Members of the management team were on call to support staff if required.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The management team were disorganised and did not have information readily available. The management team did not have a good overview or insight of the service. Audits in place did not identify concerns we found during our assessment in relation to safe care and treatment, medicines management, safeguarding, person centred care, IPC and good governance. For example, the last mattress check for 1 person stated their mattress was clean and in good condition, however, this was heavily stained and poorly maintained. There was no oversight from the management team to ensure weekly checks completed by the maintenance person were continued during their leave. For example, fridge temperatures in the overspill store had not been completed since week commencing 16 June 2025 and no checks identified the untidy room and the dirty fridge seals.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. We found some people had not been appropriately referred to external professionals who could support staff in delivering better care. Where people had been referred to healthcare professionals, there was limited information to evidence their advice had been followed. There were limited opportunities for people to interact as part of the community.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. At our last inspection we rated the home requires improvement with a recommendation to improve IPC practices and governance systems. At this assessment we found these areas had not been achieved and the service had deteriorated to a rating of inadequate. This evidenced the provider, staff and leaders had not taken action to learn and improve the service. This had a negative impact on the quality of service offered to people living at the home. The provider sent us an action plan setting out their intention to improve the service.