Stoneygate Ashlands

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

We reviewed four quality statements in the well-led domain. We identified the service had made improvements following our previous inspection however, shortfalls remained. Systems and processes to monitor the service needed to be fully embedded such as the providers internal auditing process arrangements together with some audits which lacked detail. People were provided with person centred care although additional improvement to the provision of activities for people cared for in their bedrooms required attention based on the feedback we received. The provider and registered manager were open and transparent with the assessment process, accepted our findings, and immediately acted to resolve the issues identified during the inspection. There was an inclusive and positive culture and leaders were visible in the service offering support and guidance to staff. Managers were accessible to people and their relatives. The service had positive relationships with other stakeholders and visiting health professionals were complimentary about the leadership and their joint working arrangements. Staff said they received support from managers in their roles and could speak up if they had any concerns.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff confirmed there was clear direction from managers about their roles and responsibilities and they were supported well. A staff member said, “I get good support from the manager, they are always helpful and they are always here. and the training is really good." Access to a range of internal and external support services was available to all staff. These included, but not limited to, paternity/maternity and adoption, information on the menopause and a well-being section within the providers EAP (employee assistance programme). Feedback from staff about the EAP was positive. The registered manager and regional director told us the culture at the service had improved since our last assessment of the service. The management team worked proactively with external organisations, as well as professionals and acted promptly to any concern raised.

All of the feedback we received confirmed managers were visible and accessible to staff, people's visitors and visiting health professionals. Managers and staff were well supported by the senior management team which included, a compliance manager, a regional director and the nominated individual. Managers were open and transparent with the assessment process, they accepted our findings openly and addressed any concerns we identified during or immediately after the assessment.

Staff confirmed they were listened to and respected. Staff felt comfortable raising concerns and were confident managers would address these. Staff reported an improved culture and were aware of the provider’s policies about how to raise any concerns and felt confident to use these. A staff member said, “I know what to do and who to inform. I would report to you [CQC], but I haven’t had to."

Processes to support staff to speak up were in place. This was both internally with managers and at provider level. A whistleblowing policy was in place to which staff had access to. Staff were encouraged during team meetings to share any concerns or suggestions.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff knew their roles and responsibilities. Senior care workers confirmed they had received additional training and support to undertake their roles for example, medicines. Staff were aware of the importance of confidentiality aligned with the general data protection regulation (GDPR) policy. Staff had access to the provider’s emergency plan that included contact details in the event the service was impacted. Staff told us their responsibilities for completing records. The registered manager and regional director told us the governance of the service had improved following our previous assessment and people, relatives, staff and professionals were more positive about the service.

Improvements had been made in response to our previous inspection to the overall governance at the service. However, some minor shortfalls remained with the deployment of staff during mealtimes, and auditing of some equipment including call bells and wheelchairs. The registered manager and regional director were prompt in their response to these shortfalls, fully accepted them and resolved them during the inspection. The provider had a new compliance process system in place to ensure oversight of the service was robust. They visited the service periodically to audit the service's performance and safety and report on any areas identified where improvement was needed. In line with the provider's policy a follow up visit should be planned for between six to twelve weeks later. Our assessment took place five weeks after the previous audit of September 2024 and no return visit was planned. There were outstanding actions from this audit yet to be completed. Whilst we identified no concerns or impact from the outstanding actions at the time of our assessment it meant it was unclear by when these actions should be completed by. This meant the providers overall oversight of the service in line with their new system was not yet fully embedded. The provider had quality assurance processes that enabled people, relatives, staff, and professionals to share their experiences of the service. The registered manager and provider understood their regulatory responsibilities and had submitted statutory notifications as required.

Whilst the provision of activities had improved, some shortfalls remained. Feedback from people who were cared for in their room told us choice and involvement was limited. One person told us, "No one spends much time with me." Another person told us, "Sometimes they come and have a chat but that's about it." People we spoke with, including their relatives for those people who could access communal activities and visit the local community were satisfied with the activities provision on offer. People's healthcare was monitored and external health professionals were contacted promptly. People and relatives told us A GP visited the service weekly.

Feedback from staff on the provision of activities in the service was also mixed. This corresponded with feedback from some people we spoke with. The activities coordinator confirmed they worked weekday mornings at the service then left to undertake activities in the afternoon at a sister service on the same site. There was no activity programme offered during weekends. Staff told us how they worked with external health and social care professionals to support people to achieve positive outcomes and how they received individual and group feedback from them praising their commitment to maintain and improve people’s lives. Managers confirmed they held positive relationships with external stakeholders including the local authority commissioning teams and health professionals.

Feedback from partners was very positive. We spoke with three visiting professionals during the assessment who individually praised the management and staff. One told us," Staff are responsive. They 100% follow my guidance and recommendations for people I treat here for wounds, pressure care and insulin management. The staff work with me and it's a home I look forward to visiting and have no concerns about care here."

The processes and arrangements for collaborating with some people at the service who were not as independent as others needed improvement. This would, as much as practicably possible, provide equal opportunity to everyone at the service to engage in activities and occupy their time in a more meaningful way. The management team were liaising and working with external partners effectively to maintain and improve their outcomes. Regular meetings were held with external partners so people’s individual needs could be reviewed.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.