Ashby Court

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

Risks to people had not always been properly assessed to decide how likely it was that someone could be harmed and how serious that could be. The systems and processes had not identified the concerns relating to risk. The registered manager told us they promoted a positive culture where they worked closely with people to ensure they were safe and happy. Staff told us the senior team was very supportive, however actions weren’t always timely when issues had been raised. Staff meetings were held regularly so staff had an opportunity to have their say and share ideas. Staff we spoke with told us they felt confident in speaking up if they needed to. Audits were completed and any concerns highlighted were put into action plans so they could be addressed. We could see evidence that actions had been completed. However audits had not always identified the concerns we found at our assessment.

This service scored 64 (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 told us they promoted a positive culture where they worked closely with people to ensure they were safe and happy. A staff member told us, “Everyone looks out for everyone. It's a location that's a proper team - not just 1 person doing 1 thing and another person doing something else. People say it feels like it's family, that staff are family. It’s all about [people] being happy.”

Staff were given the opportunity to learn and share information at team meetings as well as in supervisions. Records of meetings and supervisions were documented.

Although staff told us leadership was good, they told us that sometimes when they had raised minor issues, actions that needed to be taken weren’t always addressed in a timely manner. Staff we spoke with told us there were opportunities to progress in the company and the registered manager was supportive and understanding.

The manager had regular staff meetings where there was opportunity for staff to raise points to discuss or share ideas. There was evidence staff were supported with regular supervisions.

Staff told us they felt able to speak up about any concerns they had. Staff told us regarding minor quality concerns that actions were not always taken or actions taken were not effective. They told us that issues were often brought up in team meetings instead of being dealt with directly which meant that standards were slipping. Staff told us they were not aware of a way they could raise any concerns anonymously.

The provider had a whistleblowing policy but there was no procedure for anyone to raise a concern anonymously if they did not feel confident to do it in another way.

Staff we spoke with told us the provider was accommodating and flexible with work patterns. They told us work patterns had been completed with their agreement and consultation but predominantly were for the best interests of the people they supported.

The provider had policies in place to ensure staff were treated fairly. The provider had a policy on equality and diversity.

The registered manager told us they completed regular audits to assess the quality of the service although we found these were not always effective in identifying all concerns. The registered manager stated they were well supported and had independence to manage the service and carry out their role.

The provider had governance systems in place, but these were not always effective in supporting people to consistently receive safe care and support. Risks to people had not always been properly assessed to decide how likely it was that someone could be harmed and how serious that could be. Additionally, not all potential risks had been identified. For example, for a person who accessed the community independently the only risk assessed was around road safety. However, there were multiple risks associated with that person that had not been considered. We fed this back to the registered manager who then reviewed risk assessments; however they were still not sufficient to show they had identified and assessed risks with clear actions on how risk could be reduced. Care plans did not always give enough detail on risks that were still relevant. A person’s care plan did not provide enough detail and we had to seek further information from the registered manager and other professionals to ensure we had an accurate overview of the person. This meant staff would not have the appropriate information in the care plan to support that person effectively. Monthly quality audits were completed and there was evidence that actions from previous months had been completed in line with the prospective timescales.

People told us they were supported by staff for any medical appointments or appointments with other services.

The registered manager told us they referred and supported people to services when required. We could see evidence of this in care plans.

A professional had no concerns about the service. A nurse from the GP service told us they had no immediate concerns during their most recent visit.

Records seen showed involvement of partners and how working with others had provided good outcomes for people.

Staff felt involved in being part of service development and improvement. They told us they could raise suggestions at any time to help improve the quality of the service. Although regular team meetings were taking place, there was no evidence that action plans had been created to improve the quality of the service.

The provider had systems in place to seek feedback from people and staff. We did not see any evidence on how the feedback had helped improve the quality of the service or if any actions had been taken. We reviewed a recent incident which showed that actions had been taken following this to learn and reduce the risk of reoccurrence. Information had been incorporated into the care plan and risk assessment.