During an assessment under our new approach
About the service
Ashley House is a care home providing accommodation for people who require nursing or personal care. The home is registered to accommodate up to 16 people. There were 14 people using the service at the time of our assessment. There were 2 registered managers, 1 of whom supported our assessment visit.
Who the service is for
Ashley House specialises in supporting adults with mental health conditions.
Key findings
We carried out this assessment between 26 and 28 October 2026. This service was previously rated as good. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.
People’s needs were fully assessed before they moved to the home, and initial assessments informed care plans. However, care plans were not always updated promptly to reflect people’s current needs or reviewed in line with the provider’s expectations. The registered manager told us they would improve oversight and audit processes to address these shortcomings.
Staff said staffing levels were sufficient to support people to go out and take part in activities they wanted to do. Staffing levels were increased when people’s needs changed. However, staff reported additional pressures at weekends, when no staff members were allocated to prepare meals or help clean communal areas.
Staff told us they received regular training and felt confident in supporting people living at Ashley House. However, some felt the on-line training could be improved by focusing on people’s specific needs.
Staff worked with people to help them understand and manage risks to their health and wellbeing. They respected people's right to make unwise decisions while recognising their responsibility to keep people safe. For example, the registered manager explained how, with support from a health professional, they had given 1 person information to help them understand risks around their use of a medication. Managers and staff understood when they needed to act to safeguard people from potential abuse and harm, introducing plans to mitigate identified risks. Staff told us learning from incidents was shared with them, so they understood how to support people.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be provided through the Deprivation of Liberty Safeguards (DoLS), which form part of the Mental Capacity Act 2005 (MCA). We checked whether the service followed the principles of the MCA and how it managed DoLS. Staff and managers worked within the MCA, and DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions and staff understood the importance of gaining consent and considering any potential restrictions when providing care.
Staff monitored people’s health regularly and referred them to the local GP practice or mental health services when changes or deterioration were identified. Staff supported people to attend regular psychiatric and medication reviews, and access optical, dental and chiropody services. One health and social care professional told us, “During my review visits, I always meet with staff to receive a handover prior to seeing the person, then have a staff member present during the formal meetings with the person and their relatives. Information handed over is always appropriate, clear and relevant.”
People received their medicines as prescribed. However, ABC (Antecedent, Behaviour, Consequence) charts were not completed to record and monitor episodes of distress or agitation. These charts record what happened before, during and after an episode to help identify patterns, effective distraction strategies and when people needed their ‘as required’ medicines to be administered. The registered manager acknowledged this was an area for improvement and agreed to introduce these.
Care plans generally reflected people’s communication, health conditions, emotional wellbeing and support needs. However, they were not always updated promptly or aligned with people’s longer-term goals. Despite this, staff knew people well. They gave examples of how they used this knowledge to tailor care and respond to people’s needs at the time, including reducing anxiety when people were in communal areas with others. One staff member told us, “Getting to know the people here is important. You have a chance here to build a relationship with people.” Another staff member commented, “I think we have got so many different and diverse care needs. You have to have your hat on to think about each person's care needs and you have to swop your hat quite a lot just to meet those needs.”
Records demonstrated staff listened to people to understand what was important to them. For example, 1 person’s care plan contained an agreed strategy for decluttering their bedroom while respecting their privacy and recognising the importance of their personal belongings. This approach had helped the person participate in developing their risk management plan.
Staff recognised the importance of encouraging people to make choices and do as much for themselves as possible to improve their sense of wellbeing and purpose. One staff member explained, “People are looked after well. The way nurses approach the residents and give them options encourages independence. Colleagues said not to do everything for them, to let them do things for themselves, even cleaning their rooms. It’s about making sure people feel independent and valued.”
Managers and staff were committed to ensuring people with protected characteristics were treated fairly, had equitable access to support and achieved positive outcomes. Staff understood how people’s characteristics, backgrounds and health conditions shaped their experiences. They advocated for people to access external healthcare appointments when needed and worked with other healthcare professionals to adapt appointments to people’s individual needs, reducing distress and addressing health inequalities. For example, appointments were arranged around 1 person’s important routines. Another person always had appointments at the same time and with the same healthcare professional to reduce their anxieties. The registered manager explained, "We are here for them and not for us. Most of our residents, have no family and no one advocating for them. If it is not us, who is going to call it (discrimination) out.”
When people needed an emergency transfer to hospital, staff accompanied them and supported them through the admission process.
Staff respected people’s history and religious beliefs and people were supported to follow their faith and attend services. Where people had dietary needs related to their faith or culture, this was respected and facilitated.
Staff were positive about working at Ashley House and spoke with care and empathy about the people they supported. Staff described good teamwork to ensure people’s needs were met but felt communication could be improved across shifts. The registered manager agreed improvement could be made to handover information recorded within the care planning system.
The provider had a system of checks and audits to assess the quality of the service. However, audits were generic rather than tailored to the specific service. Completion was not recorded for some actions identified through audits, limiting assurance that risks had been addressed. Learning identified through these processes had not always been implemented promptly. While we found no impact on people’s outcomes, the registered manager acknowledged this was an area for improvement.
On the first day of our assessment, we found some environmental issues related to window restrictors and fire safety. The provider was responsive to our feedback and took immediate action to address the areas for improvement identified.