Ashley House - Langport

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

At the last inspection we identified a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Systems and processes were not operated effectively to assess, monitor and improve the quality and safety of the service. At this assessment the systems to monitor the quality and safety of the service had improved and the provider was no longer in breach of regulation 17. There were a range of audits and checks carried out by the provider and registered manager. These identified areas of improvement and a service improvement plan was in place. Statutory notifications had not always been submitted as required to the CQC. We identified 2 statutory notifications had not been submitted. Retrospective notifications were completed by the registered manager during the assessment. All other notifications had been submitted as required. There was a visible and caring management team who, with staff, fostered a culture that delivered good quality care and outcomes for people in partnership with external professionals. The registered manager knew people well and was passionate about providing good quality and person-centred care. The registered manager adopted an open-door policy, and staff were encouraged to whistle blow if they felt the need. Staff felt confident to speak up and that they would be listened to. There were systems in place to share learning. Staff were aware of their roles and responsibilities. The provider had policies and procedures to make sure staff were fairly recruited and treated. The aims of the service were adopted by staff and staff worked well together as a team.

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 registered manager was passionate about delivering high standard and compassionate care which was person centered to meet people’s needs. The providers website stated, ‘We make sure all the people who live with us receive the highest quality of care and experience the best life possible.’ The registered manager reflected these aims in their day to day practice. Staff were clear on the aims of the service and spoke positively about their work and the people they supported. One staff member told us, “We are here to give them [people] the best quality of life and care we can, keep them happy and safe and be as independent as they can. I do like working here. It’s good, like a proper home.” The registered manager was aware of their role and legal responsibility to be honest with people when things go wrong and learn from any incidents.

The provider had clear aims for people living in their homes. The providers’ aims stated, ‘Our principal aim at South West Care Homes is to provide the highest quality of care, ensuring a comfortable and supportive environment where individuality, dignity and quality of life are paramount to all residents. We aim to promote a way of life for our residents that permits them to safely enjoy, to the greatest extent possible, their rights as individual human beings.’ The aims of the service were adopted by the registered manager and staff team.

The registered manager told us they felt well supported in their role by their manager and the managing director. The registered manager told us how they had an open-door policy. They treated staff in the way they would want to be treated and focused on ensuring the staff team felt supported and included in everything. Staff told us the registered manager was approachable. One staff member told us, “[Name of registered manager] is good, we talk about anything, they are approachable, and their door is open all of the time.” Another staff member commented, “[Name of registered manager] is good, understanding and supportive.” We received some mixed feedback relating to staff feeling that they were being listened to. One staff member told us, “I do feel listened to.” Another staff member commented that when they raised concerns, they didn’t always get an outcome. We discussed this with the registered manager who gave assurances regarding the processes in place for staff to raise concerns and receive feedback. They said however they would look into this and arranged a staff meeting. We saw the areas the staff member was raising as a concern had been actioned by the registered manager. During the assessment, any concerns we raised with the registered manager were acted upon immediately and rectified during the assessment.

Statutory notifications had not always been submitted as required to the CQC. We identified 2 safeguarding notifications had not been submitted. Although appropriate action was taken to reduce any risks and the registered manager reported the concerns to the local authority, they had not submitted these to the CQC. They said this was because they had not proceeded to safeguarding enquiries. We discussed with the registered manager the requirement to submit notifications for all allegations of abuse. The registered manager ensured retrospective notifications were completed. All other notifications were submitted as required. The registered manager was visible in the home and people knew who the manager was. The registered manager held monthly meetings with people and relatives called ‘coffee with [name of registered manager]’. This gave people and relatives an opportunity to hear about any updates relating to the home and raise any questions or comments in an informal environment. Quality surveys were carried out on an annual basis to give people and relatives an opportunity to give feedback on the service. Regular staff meetings were also held to give staff updates and receive feedback.

Staff felt confident to speak up and that they would be listened to. Staff told us there was an open culture where they were able to raise any concerns. They were aware of the whistleblowing procedure and knew how to report any concerns externally if required. One staff member told us, “I feel confident to speak up and am aware it can be escalated outside of the organisation if needed.”

There was a whistleblowing policy in place and staff knew how to access this. Information on raising concerns was visible throughout the home.

The registered manager told us they treated staff fairly and how they would want to be treated. Staff told us they felt fairly treated by the registered manager and their colleagues.

The provider had policies and procedures to make sure staff were fairly recruited and treated. The provider information return stated, ‘All our HR (human resources) processes are checked to ensure there is no discrimination, including in relation to protected characteristics, when making HR, training or recruitment decisions.’ Training records reflected staff had undertaken training in equality and diversity, to promote inclusion within the staff team.

Staff were aware of their roles and responsibilities. The senior management team visited the home, staff knew the senior management team and felt able to approach them. Staff told us there had been improvements in the home since our last inspection. One staff member told us, “There have been improvements since the last inspection.” The registered manager told and showed us the progress they had taken since our last inspection to improve the service.

At the last inspection we identified a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Systems and processes were not operated effectively to assess, monitor and improve the quality and safety of the service. At this assessment improvements had been made to the governance systems and the provider was no longer in breach of regulation 17. There were a range of audits and checks in place that identified areas of improvement and action required to rectify these. Audits were carried out by the registered manager, area manager and managing director. Areas covered included, the environment, health and safety, dining experience, staffing, compliments, complaints and concerns and medicines.

People and relatives told us they were aware staff worked in partnership with other agencies to meet people’s needs. No one raised any concerns about access to specialist services. The staff worked with other professionals and groups to meet people’s needs and promote their wellbeing.

Staff and the registered manager felt they had good relationships with professionals which enabled them to meet people’s needs. They worked with local professionals to support people’s health and wellbeing. The registered manager told us about the links the home had with the local community. This included links with the local GP, pharmacy, dementia support service, church, vets, as well as entertainers coming to the home to facilitate reminiscing sessions, dance and singing.

Visiting professionals commented positively about the home. One professional told us, “People seem happy with their care, and I have seen a fantastic reminiscing activity, the atmosphere in the home appears happy and homely.” Another professional told us, “I have found Ashley House to be a very welcoming care home. There is a warm, relaxed atmosphere throughout the home. Residents appear at ease, relaxed and comfortable. I have observed staff interacting with people in a caring and considerate way.”

There were processes in place to ensure the service worked in partnership with other professionals to make sure people received the care and treatment they needed. This included GP’s, speech and language therapists, social workers and district nurses.

Staff told us they were informed of any areas where improvements were needed. One staff member told us, “We have improved since the last inspection.” Another staff member commented, “Yes things have changed, and we have got used to them, we adapt.” The registered manager adopted a culture of learning, they were committed to providing a good quality service and they responded to our feedback during the assessment.

There were systems in place to support learning and improvement in the home. There were a range of opportunities for giving feedback. This included, quality assurance surveys, coffee with [name of registered manager] meetings, staff meetings, staff supervisions and the complaints procedure.