- Care home
Ashlands Care Home
Assessment report published 29 August 2025
Contents
Ratings
Our view of the service
Date of Assessment: 08 July to 23 July 2025. Ashlands Care Home is a residential care home service providing support to older people and people living with dementia. At the start of the assessment the service was providing care and support to18 people.
This assessment was initiated due to previous breaches in regulation for safe care and treatment and good governance. We also assessed responsive as it had not been reviewed since 2019.
We found multiple environmental hazards including poorly fitted fire doors, inaccessible fire doors due to multiple locks, unsecured windows, high water temperatures, and hazardous items like rodent traps and flammable creams without risk assessments. We observed poor hygiene standards across the service. Some equipment was dirty or damaged, cleaning records were not always accurate, and kitchen practices did not meet safe food hygiene requirements. We found unclear documentation for ‘as required’ and covert medicines, and staff administering medicines without up-to-date competency checks. Medicine was discussed and given to people in public areas, affecting their privacy and dignity We saw care plans that were incomplete, inaccurate, and sometimes used language that was not person centred. Key details were missing from care plan documents used by staff to provide a guide on how to best care for people, and internal audits had not identified these issues.
Many staffs training had expired or they had missing training in key areas such as fire safety, dementia care, and Deprivation of Liberty Safeguards (DoLS). Competency records were unclear or missing. We saw that the environment lacked dementia-friendly feature which would support people’s independence. People were not supported through the use of clear signage or tools to help with orientation. Activities were limited and not tailored to individual needs. We found examples of task-led care, such as fixed shower routines and weighing people in public areas. People were not always given choices or involved in decisions about their care. We saw that the manager was making improvements, but many systems were still underdeveloped. Audits were not effective, and strategic goals were unclear.
Audits failed to identify significant issues in care quality and safety. Risks were not adequately assessed or mitigated. The provider did not act on known issues, showing a breakdown in the feedback and improvement loop.
The provider was previously in breach of the legal regulation in relation to safe care and treatment and governance at the service. Improvements were not found at this assessment, and the provider remained in breach of these regulations.
We took enforcement action against the provider and told them to make improvements.
People's experience of this service
While many people said they felt safe and well cared for, others reported delays in call bell responses, limited activities, and feelings of isolation. Mealtimes lacked personalisation and choice. Staff were described as kind and respectful, using appropriate protective equipment and maintaining privacy during personal care. Most people felt secure, and felt healthcare needs were met promptly, with timely access to doctors and nurses. However, access to dental care was limited.
Some people raised concerns about delays in staff responding to call bells, particularly at night. While staffing levels were generally seen as acceptable, response times varied. Observations showed that communal areas were sometimes left unsupervised, and staff interactions were often task-focused, particularly during mealtimes where communication was minimal. People reported daily room cleaning but laundry issues were common, with missing or mixed-up clothing items causing frustration.
Mealtimes were functional but lacked a person-centred approach. Food was generally well received, though portion sizes were often too large and alternatives not clearly communicated. One person told us, “The food is very good, impressive, if we tell them we don’t like it they will make something else.” Another person said, “The food is very good.”
Some people struggled with the dining setup, and seating arrangements did not always consider people’s interpersonal relationships. We observed loud music playing which was not fitting to the environment and audience or support a relaxing dining experience.
People told us there was little encouragement to participate in activities or consultation about preferences, contributing to feelings of isolation. While some people were satisfied with their rooms and the general environment, others highlighted missed opportunities for outings or social activities. One person expressed a desire to go shopping or attend the theatre, reflecting a need for more enriching experiences. Activity provision was limited and not always tailored to individual interests. While some people took part in jigsaws, bingo, or religious visits, many spent long periods watching television.
Feelings of autonomy and choice were mixed. Some people felt in control of their routines, while others experienced limited flexibility, particularly around bedtime. People told us declining to go to bed at the suggested time could result in long waits.