- Care home
Ashley Phoenix Home
Assessment report published 14 October 2025
Contents
Ratings
Our view of the service
Date of inspection 25 June to 12 August 2025. We carried out this inspection due to concerns about people’s care and safety in the service, and to follow up on previous breaches of the legal regulation relating to person centred care, safe care and treatment, safeguarding and governance.
We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
At the time of the inspection on- site visits, there was no registered manager in post. However, the provider had successfully recruited a new manager who intended to apply to the Care Quality Commission (CQC) to become a registered manager during the inspection process. The service had oversight from the area manager, along with a peripatetic manager and the deputy manager. Eight people were using the service at the time of the inspection.
During this inspection we identified the provider was in continued breach of the legal regulations relating to safe care and treatment and good governance. However the provider had taken action to make improvements in the legal regulations related to person centred care and keeping people safe from abuse identified in the last inspection.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
The provider did not always have effective oversight of the service to drive improvements in relation to some of the issues identified during the previous CQC inspection. This meant the provider had not ensured areas of concern we identified, addressed and embedded effectively.
People’s medicines continued to not always be safely managed. Further, care plans sometimes lacked detail such as how people preferred support with inhalers or guidance for ‘when required’ (PRN) medicines was missing for some medicines. Additionally, one person’s care plan had not been updated to reflect their changing needs and guide safe practice. This meant there was an increased risk the person could be harmed. The provider updated medicines and care planning information during the inspection process. Governance systems and audits were not always effective in identifying or addressing areas for improvement.
However, the provider had identified shortfalls in the historical management of incidents and accidents. This included referring to the relevant bodies and had started to address this. They demonstrated transparency by sharing the shortfalls with the Local Authority.
Staff were recruited safely and trained to meet people’s needs. Some staff had received Deafblind British Sign Language training, and detailed guidance was available to help untrained staff communicate effectively with people.
Most people’s care planning information contained clear detail about how people like to be supported and how to help them during times of distress. Leaders and staff knew about people’s needs and their likes and dislikes. People were supported to do things they enjoyed doing. For example, going out for walks or to the shops and were enabled to take positive risks in their lives.
People's experience of this service
We were unable to speak with people who used the service because of their limited verbal communication. Instead, we completed a wide range of observations including using the Short Observational Framework for inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We observed people appeared to be happy and comfortable with the support from staff. People appeared to move confidently around the service when they wanted to do and do activities they enjoyed doing. For example, knitting, taking part in meal preparation or having a glass of wine which they had purchased from the shop. We spoke with 4 relatives. Most relatives were happy with the care their relative received. Relatives told us, “We never have to worry with her there, it all runs very smoothly. Another relative said, “[Relative] is always happy to return to the service and waves goodbye happily. She likes to go back and get settled in for the rest of the day.” However, one relative expressed a dissatisfaction and did not feel their relative was safe in the home and felt they had not always been informed about incidents.