Ashley Court Care Limited

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• 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

Our rating for this key question remains requires improvement. The service was not always well-led. We identified 1 breach of the legal regulations. The systems in place to monitor and improve the home were not always effective. There were no systems in place to ensure people received the care they needed. Other checks and audits were not always effective in identifying concerns and areas of improvement. There was a positive environment in the home. Staff were involved and supported and felt they could raise concerns if needed.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although we were not made aware of any values of the home the registered manager told us they worked hard to ensure they got on well with all the residents and their families. Staff felt they all worked together to ensure the home was a nice environment for people to live in.

There were processes in place to ensure there was a positive culture in the home. Staff who worked in the home had been there a long time and the turnover of staff was low, creating a positive environment.

During our conversations with the registered manager and deputy manager they were unable to demonstrate they understood the importance and process of auditing. For example, the registered manager told us they audited pressure monitoring charts, however what they explained to us was not an audit but a review of the information. Staff felt the home was a nice place to work and felt supported by the registered manager and deputy. They told us they had the opportunity to raise concerns and felt they were listened to and involved with the running of the home.

The lack of understanding from the registered and deputy manager as documented above meant the governance systems in place were not always effective. This led to a lack of oversight in relation to the safety and quality of care provided. Care staff were aware of their roles and responsibilities.

The registered manager told us they offered an open-door policy and were confident staff would raise concerns with them if needed. They confirmed there were whistle blowing policies and procedures in place. Staff we spoke with were aware of the whistleblowing policy and felt confident to speak up if needed.

There was a whistleblowing policy in place and the home had created an environment where staff were able to speak up and raise concerns when needed.

The registered manager told us their workforce was important to them and this was reflected in the low turnover of staff. They told us there were policies in place to ensure staff were supported with their individual needs. Staff told us they were happy working in the home and felt they were treated in a fair way.

There were procedures in place to consider staffs’ individual needs, this included considering staff’s diverse needs and treating all staff fairly and equitably.

The registered manager told us they monitored people’s care by reviews, however confirmed there were no audits in place for this. They told us they were using the action plan from the local authority to make improvements.

The systems in place were not always effective in identifying areas of improvement. For example, the medicines audit that was competed had not identified people did not have guidance in place to manage ‘as required’ medicines. Although planned reviews of people’s care records took place, there were no audits in place to monitor the care people received, resulting in people being exposed to the risk of harm. Checks were completed on the environment to ensure it was safe and to monitor infection control.

People and relatives raised no concerns to us. A relative told us, “The district nurse comes in every day.”

Both leaders and staff felt they worked in partnership with other agencies. The deputy manager confirmed they did not always have the most up to date information available in people’s files following input from health professionals.

As part of this assessment, we asked for feedback from the local authority. They told us they had completed a site visit of Ashley Court Care Home and found areas requiring improvement. This included concerns with care records and the environment. They had worked with the provider to put in place an action plan, they sent us a copy of this plan to review. We found the provider had not worked in a timely way to ensure the areas of improvement highlighted by the local authority had been actioned.

The provider had failed to work in a timely manner to ensure concerns identified by the local authority were actioned. We found some of the concerns identified by the local authority had been marked as ‘urgent’ following their visit in June 2024 had not been addressed. For example, care plans and risk assessments had not been improved urgently to mitigate the risks posed to people. The local authority had also raised concerns around aerosol cans being stored on radiators, and the storage of equipment that posed a risk, we again observed these concerns during our site visit. There were systems in place to ensure they worked in partnership with other agencies. The home worked with other agencies including the district nurse team and the community mental health team to ensure people received the support they needed. We could not be assured advice from health professionals was always followed as care plans were not always reflective of advice given by professionals, for example speech and language therapists.

The registered manager confirmed improvements were needed to ensure care plans and risk assessments were in place and reflective of people’s needs. They confirmed they had an action plan in place that had been implemented by the local authority. The registered manager told us learning was identified from safeguarding investigations. However, they were unable to tell us how they applied this more widely in the home for example, when incidents had occurred. Staff were unable to tell us how they learned from incidents that had occurred in the home.

There was a lack of effective systems in place that identified concerns and drove improvements within the home. When incidents and accidents occurred, there was no evidence these had been reviewed to ensure future risks were mitigated and this information had not been reviewed so that lessons could be learnt.