Ashleigh Manor Residential Care Home

Updated 3 February 2026

Date of assessment: 28 April 2026 to 15 May 2026.

Ashleigh Manor Residential Care Home is a 'care home' that provides care and support for a maximum of 65 older people, some of whom are living with dementia and/or physical frailty. At the time of the assessment,55people were living at the service.

The purpose of this assessment was to check whether the Warning Notices served in relation to breaches of regulation for safe care and treatment, safeguarding and governance following our previous assessment in September 2025,had been met. Our assessmentidentified7breaches of legal requirements in relation to safeguarding, safe care and treatment, need for consent, person-centred care, dignity, staffing, and good governance.

People were not always protected from the risk of harm because staff did not consistently have all the information needed to meet people’s needs safely. Following the previous assessment, the provider and registered manager had taken some action to improve the service. There were improvements in areas such as aspects of medicines management, the recording of topical medicines, and the environment, including reduced odour and some improvements to infection prevention and control. Governance systems had been strengthened and there was evidence of increased leadership presence and engagement with staff. Staff and external professionals also provided some positive feedback about the caring approach of staff and communication within the service.

However, these improvements were not consistently embedded and did not ensure people always received safe, person-centred care. Evidence from care records, staff feedback and direct observation showed ongoing and widespread concerns. Care plans and risk assessments were often generic, inconsistent or contained conflicting information, and did not always reflect people’s current needs. This meant staff did not always have clear guidance to provide safe care.

People were not always protected from avoidable harm. The management of risks relating to falls, skin integrity, nutrition, epilepsy and environmental safety was inconsistent. In some cases, identified risks had not been assessed or mitigated, and staff did not always follow care plans. Medicines were not always managed safely, with gaps in administration records, issues with storage and a lack of clear protocols for some high-risk medicines.

People’s rights were not always upheld. The provider did not always follow the principles of the Mental Capacity Act 2005. We found inconsistencies in capacity assessments, best interest decision-making and the use of restrictive practices. Some restrictions on people’s care and movement were in place without appropriate legal frameworks or clear documentation.

Staffing systems did not always ensure staff had the skills, training and support they needed. Training records showed gaps in mandatory training, supervision and competency checks were not consistently effective. Staff told us they often relied on verbal handovers rather than care records, which increased the risk of inconsistent care delivery.

Governance systems remained ineffective in identifying and addressing risks. Although audits and oversight processes had been introduced or strengthened, they had not identified the concerns we found during this assessment. This meant leaders did not always have an accurate understanding of the quality and safety of the service.

At this assessment, the overall rating remains inadequate. This service remains in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

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. In addition, we have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 3 February 2026

We spoke with 14 people living at the service and gained feedback from 7 relatives to help us assess and understand how people’s care needs were being met.

Feedback from people living at the service, relatives and visiting professionals was mixed, with many describing kind and caring interactions with staff, but some highlighting inconsistencies in care,communicationand responsiveness.

Most people told us they felt safe and supported. Comments included people feeling reassured that staff “check on us” and respond when help is needed. However, some people and relatives also told us staff were often busy and at times there were delays in responding to requests for support, particularly when call bells were ringing or when staff were supporting others with higher needs.

Several people told us staff “know my little ways” and treated them with respect. Relatives also gave positive feedback about staff compassion, particularly during times of illness and at the end of life, where they said staff had been supportive and attentive both to the person and their family. However, our observations did not always reflect these experiences. For example, we saw some people’s bedroom doors left open, meaning privacy was not always maintained, and practices within the service did not always promote people’s dignity.

People spoke positively about activities and opportunities to socialise. We observed group activities such as quizzes, games and music sessions, and people told us they enjoyed these and valued having things to do. Some people also went on trips and participated in meaningful one-to-one engagement. Staff described efforts to tailor activities to people’s preferences and interests. However, relatives told us opportunities for engagement were sometimes inconsistent, and people who were more independent or living in communal areas were not always meaningfully engaged.

People generally felt they had enough to eat and drink and were offered a choice of meals. We observed staff encouraging people to eat and drink and offering alternatives. Relatives were mostly positive about the quality of food and support provided, including monitoring weight and involving health professionals when needed. However, some people gave mixed feedback about meal quality, consistency and temperature.

Some relatives told us they were kept informed of changes and involved in decisions, while others said they had not been involved in care planning or reviews and were unaware they could access care records. There was also inconsistency in how people were supported to express their views or concerns. While many said they felt able to speak to staff and be listened to, others described needing to seek out updates themselves.

People and relatives raised concerns about aspects of the care environment and personal care. Some felt areas of the home and people’s rooms were not always maintained to a good standard, and concerns were raised about the consistency of support with personal hygiene. During the inspection, we also identified concerns in relation to the environment, including fire safety and cleanliness issues in some areas.

Where people were unable to communicate their experiences directly, we used observation to understand how care was delivered. We observed some positive, caring interactions between staff and people, including reassurance, encouragement and supportive communication. However, we also observed practices did not always reflect person-centred care, and where people’s individual needs and preferences were not consistently recognised or respected.

Overall, while many people and relatives described caring relationships with staff and positive day-to-day experiences, our assessment found people’s experience did not always reflect the quality and consistency of care being delivered. Systems and practices in the service did not always ensure people received safe, personalised and responsive care, and some of the risks identified during the assessment were not reflected in people’s feedback.