Ash House

“We assessed the service against ‘Right support, right care, right culture’. This guidance supported judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choice, independence and access to local communities that most people take for granted.”

“The service was in breach of 2 legal regulations in relation to safe care and treatment and good governance.”

“Professional guidance was not always embedded into practice, which meant people with a learning disability and/or autistic people were not consistently supported in line with their assessed needs. Incidents were not always followed up robustly, and there were delays in escalation, in complete records gaps, and limited evidence that learning from incidents was used to reduce future risks. This reduced assurance that people were supported safely and proactively, particularly where they relied on staff to recognise and respond to changes in their needs.”

“Medicines management systems were not always effective, as medication fridge temperatures were not consistently monitored within recommended ranges and there was not always clear evidence of timely action or escalation.”

“Governance and quality assurance systems were not always effective in identifying and addressing concerns. Although the provider completed audits at service and provider level, including an independent audit, these did not consistently result in sustained improvements, and previously identified issues had not been fully resolved at the time of inspection.”

“Following feedback, the provider shared actions taken, including increased management oversight and additional monitoring arrangements. However, these measures had been recently introduced and were not yet embedded, so we could not be assured that governance systems were effective at the time of inspection.”

“However, staff and relatives spoke positively about the leadership and management of the service and told us they felt supported and were able to raise concerns. The management team were responsive during the inspection and feedback process.”

“We have asked the provider for an action plan in response to the concerns found at this assessment.”