Ashton Court Residential Home

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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

During our assessment, we have identified a breach in relation governance. We assessed 2 quality statements in the safe key question and found areas of good practice and concerns. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Though the assessment of these areas indicated areas of concern since the last inspection, our rating for the key question remains good. There was a new management team in place. Staff spoke highly of this management support and felt it had resulted in some improvements to the service. There was a lack of clear audits in place at the service. The new manager had identified this and explained that they were going to arrange audits. They had created an action plan to make improvements. While staff felt that any of their concerns would be acted on, there was a poor policy to support this practice. We saw that incidents had not been overseen, as referrals had not been made to the local safeguarding team as expected. We have asked the provider for an action plan in response to our concerns.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt confident that any concerns they raised to the management team would be listened too and acted on.

The service had a policy on how staff could whistle-blow to external agencies if they had concerns. However, we saw this policy was poor quality. It referred to legislation that has since been replaced by the Care Act (2014). The policy guided staff to refer to external agencies but did not provide contact details for these agencies. If staff were to refer to this policy, it could impact their ability to speak up about their concerns.

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.

There had been some recent changes in the management team at Ashton Court. Staff spoke highly of the current management team and the impact they were having on the service. One staff member said, "Things are getting good now. There has been a bit of turnover of other managers, but I'm reassured by the current management team". Another staff member said "[Manager name] communicates really clearly with us. It's clear how we can improve." The management team explained that they had completed an audit and identified some areas that needed improvement. They were open and transparent with the CQC about the risks at the service and how they intended to make improvements.

There was a limited number of routine audits being completed at the service. The new manager explained that they had already identified this and planned to put these audits in place. They sent an action plan to the CQC, with a description of how they intend to further improve the service. We identified three incidents where service users had been in a verbal or physical altercation with each other. These incidents are considered to be a safeguarding, as vulnerable people are at risk of abuse. The provider is legally required to notify the CQC of allegations of abuse, however due to poor oversight processes these incidents had not yet been recognised by the management team and the CQC had not therefore been notified.

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

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.