Ascot Lodge Nursing 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 of this key question, we found that there had not always been sufficient oversight to fully monitor the quality and safety of the service. However, action plans were in progress to address some of the concerns found by external agencies. Where action plans were not in place, concerns highlighted on our visit were addressed immediately. We received mixed feedback from partners about the service. Staff were positive about the management team and the support they received. People and relatives felt the service was managed well and overall were kept well informed. Staff and relatives told us the service had improved with positive changes implemented.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team encouraged people and relatives to express views and concerns. They listened and acted on them to help shape the service and culture. Staff said they able to make suggestions and contribute to the development of the service. One staff when asked if they had the opportunity to share ideas replied, “Definitely. We share ideas and try them out and if they don’t work we try something different.”

The provider had a visions and values statement, but this needed further promotion within the service to ensure staff were aware of and shared this vision. Staff at all levels were seen during our visit to promote a positive culture that was person centred, open and inclusive.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 felt confident in raising concerns should they need to and told us that they felt their concerns and ideas would be heard. One staff told us, "I will tell [Name of registered manager] and [person] will sort it out. We know the door is open.” The senior team acknowledged the shortfalls identified at this inspection and were eager to put processes in place to ensure people receiving care and support were safe and protected from harm.

The systems to assess, monitor and improve the service were not sufficiently robust. Monitoring by external agencies had identified issues which were not identified by the systems in place at the home. These systems needed review to enable the service to be more proactive than reactive. Issues picked up during the inspection were noted to be actioned immediately. Records of care and support were not always accurate or up to date and staff did not always have access to clear information about the people they were supporting. Improvements were required in relation to records to ensure the service were following the principles of the Mental Capacity Act (MCA). A new electronic recording system was to be introduced. Systems were in place to manage this and ease transition. The provider agreed to review all records as part of this transition to ensure all information in the new system was in place, up to date and accurate. Safeguarding and CQC notifications had not always been submitted as required. Revised systems were noted to be in place to ensure all events that needed notification to external agencies were completed within the identified timescales.

Overall people and their relatives were positive about their experience of the team at Ascot Lodge. One relative told us, “The service is well run, and I cannot fault anything. I am so impressed I would recommend this home to anyone.”

The management team were committed to improving the service and were open to suggestions for improvement, recognising the importance of joint working with partner agencies and families. Staff were also aware of the value of working in partnership, with professionals, people and with other staff. One staff commented, “I feel we work as one team.”

Overall, partners felt that the team at Ascot Lodge were responsive, but some felt that the service could be more proactive in identifying concerns rather than reacting to issues raised. At the time of our visit the home was working to an action plan from the Local Authority and Integrated Care Board (ICB) and a review of new admissions was in place. A separate action plan was also in place for Infection Prevention and Control (IPC). The provider acknowledged the service had received concerns from the local authority/ICB and that they had taken action to address these concerns.

Records seen evidenced involvement of partners. However, some care records needed more detail and processes making more robust to enable effective information sharing between the service and healthcare professionals. The service was working with the GP and Pharmacy to resolve issues regarding the ordering of some medications.

The senior team were committed to improving the service. However, systems and processes in place did not always identify concerns or issues raised by other agencies. Staff told us they were encouraged to contribute their ideas about what the service did well and what they could do better during regular team meetings. A member of staff told us, “We raise concerns if they need raising and sort things after the meetings.” Staff could describe the benefits of the support and training they received and the opportunities the provider offered for personal development.

The provider had structures in place to monitor and improve the quality of care they delivered. However, these needed review to ensure they were robust and learning from incidents was sustained and embedded across the service. The provider had systems in place to seek and act on feedback from people, families and staff and improvement plans to take the service forward. The provider had invested in a new electronic recording system which they said would assist them in monitoring and improving care. The senior team worked with staff to understand how things went wrong and involved them in finding solutions.