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Ashleigh Nursing Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 5 November 2019

About the service

Ashleigh Nursing Home is a care home providing personal and nursing care to 16 people aged 65 and over at the time of the inspection. The service can support up to 21 people, in one adapted building.

People’s experience of using this service and what we found

Systems and processes such as regular audits, the recording and reviewing of accidents and incidents were neither scheduled or planned. Opportunities to reflect upon, and develop the quality of the service through meetings, staff supervision and appraisal did not routinely take place in line with the provider’s policies and procedures. The failure to implement these systems and processes, meant opportunities to assess and develop the service through effective review and engagement were missed.

Systems and processes to promote people’s safety and welfare were not consistently implemented. Potential risks to people were identified. However, checks did not routinely take place to ensure steps to minimise some areas of risk were acted upon.

People’s safety was compromised, as the systems to promote people’s safety and well-being were not consistently implemented. Staff training in key areas to promote people’s safety, health and welfare were not up to date for all staff, which had the potential to put people at risk. People received the medicine they were prescribed. We identified areas for improvement with regards to medicine recording, which were addressed at the time of the inspection. Further improvements to documentation with regards to medicine management, would further improve medicine systems, promoting people’s safety. We have recommended the provider refers to and adopts good practice guidance for the management of medicine.

Systems to ensure people were protected from avoidable harm or abuse were not always effective. We found, an instance where a referral to the relevant authority of potential abuse had not been made.

Potential risks to people’s safety and well-being were assessed. However, systems to ensure people were not exposed to unnecessary risk were not consistently monitored. We have made a recommendation that a system for the checking of pressure relieving mattresses be implemented.

Equipment was used, such as hoists to move people safely.

Opportunities for people to engage in social activities, develop interests within the service and the wider community were limited. Activities, as detailed on the notice board did not take place, and people we spoke with told us they were not involved, or had not seen activities within the service. Staff meetings had been used to remind staff of the importance of providing activities. However, our observations confirmed staff, whilst having the opportunity did not maximise their time to encourage social interaction or activities.

People were supported to have maximum choice and control of their life, and staff supported them in the least restrictive way possible, and in their best interests; the policies and systems in the service supported this practice. People’s capacity to make informed decisions were undertaken, and where people were assessed as not having capacity to make an informed decision, then a best interest decision was made to promote their health and welfare.

People and family members spoke positively about the care provided, and confirmed they had provided information about their relatives to needs. They told us staff kept them informed as to the health and welfare of their relative. Records showed, people accessed health care services were required, and that people’s health needs were monitored.

The provider had made improvements to the environment, which had included the painting and decoration of communal areas. Further improvements to the environment had been planned, some identified improvements had been scheduled for a few days following our inspection visit, which included the replacement of floor coverings in communal areas. Systems and appliances within the serv

Inspection areas


Requires improvement

Updated 5 November 2019

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 5 November 2019

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 5 November 2019

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 5 November 2019

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 5 November 2019

The service was not always well-led.

Details are in our well-Led findings below.