Ash Hall Nursing 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

During our assessment of this key question, we found concerns around the provider’s governance systems and oversight of the service. Lack of oversight, ineffective auditing and ineffective assessment of the care provided meant concerns and issues were not routinely identified and, as a result, improvements were not made.Systems in place to promote a shared direction and culture were not always effective. Systems to ensure staff were able to provide feedback on the service were not always effective. The provider had a whistleblowing policy which staff understood. The provider was working with the local authority and other agencies to make improvements in the quality of care they deliver. Information about people’s needs and risks was not always shared with external services when required. The provider respected staff members’ individual cultural needs and were flexible in allowing them to observe them.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us there was a shared direction and culture. One staff member told us, “There have been a lot of new faces recently. There is a good core team though and staff are loyal. New staff are developing and are enthusiastic.” The registered manager told us, “I am proud of the care staff, they are the most caring people I have worked with. They really care about our residents. They reflect the values of our mission statement.”

Systems in place to promote a shared direction and culture were not always effective. Although the provider had a vision about improving their systems and the care they provided, this approach was not always effective as they did not have a service action plan in place. A service action plan would enable the provider to monitor what actions had been completed and what actions remained. It would also allow them to delegate actions and set deadlines for their completion as well as auditing how the actions were improving the service. When we told the provider about this, they put a service action plan in place and updated us on the progress of their actions.

Staff told us the leadership team was compassionate and inclusive. One staff member told us, “The management team have stepped up their game and improved a lot. I feel they are more focused on the service.” Another staff member told us, “The manager is really good and supportive. I attend one-to-one and team meetings.” A member of the leadership team told us, “We do ad hoc meetings with staff, memos and regular handovers to ensure people are updated with everything.” While staff told us the leadership team was compassionate and inclusive, we found systems to ensure staff were able to provide feedback on the service were not always effective.

Systems to ensure staff were able to provide feedback on the service were not always effective. For example, it had been over 12 months since surveys about the service had been offered to staff. This meant the provider could not effectively identify themes and trends about the quality of the care provided. The provider had procedures in place such as one-to-one meetings and team meetings to ensure staff felt valued and could raise any issues affecting their work.

Staff understood whistleblowing procedures. One staff member told us, “The manager is very approachable, and they would deal with things if needed.” Another member of staff told us, “I trust the manager to follow up any issues. I know I can inform the CQC or report to the local authority if I was worried things would not be looked into.”

The provider had a whistleblowing policy which staff understood. Staff were able to report concerns in one-to-one meetings and the registered manager had an open-door policy.

Staff told us the leadership team were respectful of their individual needs and felt included.

The provider respected staff members’ individual cultural needs and were flexible in allowing them to observe them. Staff received equality and diversity training.

The registered manager recognised improvements were required to the provider’s systems to ensure people received effective care. The leadership team was working with the local authority to make improvements however they acknowledged they were struggling to prioritise the order in which improvements were made.

The provider’s lack of oversight, ineffective auditing and assessment of the service meant concerns and issues were not routinely identified and the service was not improved as a result. Systems in place to ensure premises were secure, properly maintained and suitable for the purpose for which they were being used were not effective. Environmental audits did not identify risks of falls from height, scalding, and electrical shocks. This meant the provider could not be assured people were safe from the home environment. Systems in place to monitor and mitigate the risks relating to the health, safety and welfare of service users were not always effective. This meant people were at risk of receiving unsafe care. Systems in place to ensure care plans contained consistent, up-to-date and accurate information about their needs, risks and mental capacity were not effective. This meant people were at risk of receiving inconsistent care. Audits of people’s care did not always identify when referrals to other health and social care professionals had not been made or did not include sufficient information about their needs and risks. This meant people were at risk of not having their care needs met. Information about people’s care needs and risks could not always be located by staff. This meant people were at risk of receiving inconsistent or unsafe care. The provider did not ensure all staff training records were kept up-to-date and included specific specialist clinical training. This placed people at risk of harm. The provider did not always monitor call bell responses effectively. This placed people at risk of harm. Systems in place to involve people, their relatives and staff in the running of the care home were not effective. This meant the provider could not consistently assess feedback to continually improve the service.

People gave mixed feedback about how the provider collaborated with external services. While some people felt the provider had ensured they received the necessary medical support when needed, others felt the provider might not identify medical concerns early enough due to lack of monitoring.

Although the leadership team felt they collaborated well with external services, they had been unable to prioritise actions which would lead to improvements. Following our on-site assessment, the provider put a service action plan in place and updated us on the progress of their actions.

While we received some positive feedback from professionals supporting people at Ash Hall Nursing Home about how the care home collaborated with them, we found the provider did not always involve services effectively with people’s health needs when required and care plans did not always include guidance for staff to escalate concerns about people’s health needs.

People’s records included communication with partners such as healthcare professionals, social care teams and specialist services however information about people’s needs and risks was not always shared with them when required. This meant people were at risk of not having their needs met. The management team had a good understanding of local systems and were working with the local authority to make improvements to their systems and the care they provided.

Staff told us they had a positive approach to learning and making improvements. One member of staff told us, “The management team is fantastic. I have supervision every 8 weeks and we discuss training needs. I needed dementia training, and this was sorted. Anything I need I get.” A member of the leadership team told us, “We hold staff meetings in which we discuss learning. For example, we discussed recent issues with recording bowel monitoring. We devised a new chart where we now record these which are then transferred to an online system. We now record discussions about monitoring people’s bowels on handover records.” Although the provider was working with the local authority and other agencies to make improvements in the quality of care they deliver, a number of actions were outstanding due to the provider prioritising specific pieces of work.

The provider was working with the local authority and other agencies to make improvements in the quality of care they deliver. Following our assessment feedback, the provider put a service action plan in place to ensure there was a record of actions being completed and to enable the provider to review improvements effectively.