Ashill Lodge Care 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

The provider didn’t have a clear oversight of the service due to lack of governance and systems. This is Managers first Registered manager role and there was a lack of support in the service to support them. There appeared to be no personal development for the staff within the service apart from the Registered Manager and a team leader and no staff had, had an appraisal although supervisions appeared regularly. We were not assured the provider had good oversight of the staffs competency within their roles. There was only medication competencies carried out in the service and no evidence of staffs competencies in other areas being assessed. Some staff felt they weren’t given the opportunity to put ideas forward and there was a lack of learning throughout the service. Notifiable incidents were not always reported when they should have been. This was a Breach of good governance of the Health and Social Care Act 2008 (regulated activities) regulations 2014.

This service scored 32 (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.

When we spoke to staff in the service a lot of them stated they have not been given the opportunity to develop within the service. Talking to the Registered person we were not assured they had the experience or skills to lead their team appropriately and that they also didn't have the appropriate support to develop themselves.

The Registered Manager and Team leader were the only people working towards an accredited qualification within the service. There was no other staff progressing their personal development. There was several staff that had nursing qualifications from over seas.

We received mixed feedback from staff. Some staff we spoke with felt there was a closed culture to the freedom to speak up. When they had raised concerns previously, they felt not listened too or not taken seriously and that prevented people from raising concerns. We spoke to other staff and they felt able to raise concerns. No staff we spoke with could give us examples of things they had raised where action had been taken.

We were not assured that the service offered a positive culture to speak up. There was no evidence of staff surveys asking for their feedback or input. There was a poor culture around lessons learnt. Since we began our assessment the service has actioned to review their lessons learnt.

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.

When we spoke to the Registered Person we were not assured that they had robust procedures in place to help them identify shortfalls within the service. They could not assure us how information that they used was robustly stored, processed and monitored to deliver safe and good quality care.

We were not assured there were robust processes in place. There was a lack of HR Audits systems within the service, no overview of care plans being reviewed, no feedback from relatives or people living in the service, no plan for development for the staff. Lack of safeguarding processes followed. Lack of ensuring adequate training was provided to the staff. The service relied on a communication through a “what’s app group” where sensitive information been shared hadn’t been thought of appropriately to meet GDPR requirements. A Facebook group where peoples images had been shared without their capacity been considered in relation to displaying their photos to the members of the public.

A lot of families we spoke with weren't assured that their loved one had seen their GP regularly or that they were actively involved in their care or that their relative had any involvement from other health care professionals. 2 relatives we spoke with said they knew they saw the nurse daily due to their diabetes and another due to wounds but couldn't confirm if any other healthcare professional was involved in their care.

When we spoke to the Registered person they felt they were supported by the community Matron who would visit the service on a weekly basis to review a number of people. They felt they had a good working relationship with them. They also have Community District Nurses that attend the service to see some people with wounds. We are not assured that there is effective communication between the services due to wounds being recorded incorrectly and resulted in notifiable reports not being sent. However the Registered Person is working on this and implemented measures to mitigate this occurring again and ensuring information is fed back to leadership team prior to leaving the service and carrying out a lessons learnt with their own staff. The service has started to work with the local community and try and engage with it more but it is too early to assess the effectiveness of it currently.

Part of our assessment was triggered due to feedback from healthcare professionals raising concerns within the service. Although we spoke to the community matron and they expressed a good working relationship with the service we were not assured about the amount of information shared due to the concerns we had identified within our assessment around the review of peoples when required medicines and also there risks of malnutrition and diabetes care planning.

There was not effective or robust processes in place and we had identified people within the service where they required healthcare professional reviews of their current care needs. When we addressed this with the service they arranged these reviews to take place but we also contacted the services GP practice for additional assurances and requested their input and they arranged a review of all the people within the service.

Some staff felt they had improved their learning through lessons learnt within the service however a lot of the staff couldn’t give examples and not all staff agreed. Some staff felt they weren’t asked to put ideas forward. We asked the Registered Person about the opportunity for learning's from other services and networks to implement improvements In the service and they expressed they hadn’t had the opportunity to do this yet.

There was a poor culture around learning improvement. The service didn’t have a robust Lessons Learnt process in place and they weren’t capturing areas of improvement from situations that had occurred from within the environment. The service had an improvement plan, but it wasn’t being used robustly. There was no evidence of actions being identified within the service being incorporated into the improvement plan. There was actions on the improvement plan that were not clear on what they were, what was required and if they were complete.