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Ashleigh Manor Residential Care Home Requires improvement

We are carrying out a review of quality at Ashleigh Manor Residential Care Home. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 8 August 2018

The inspection of Ashleigh Manor Residential Care Home (“Ashleigh Manor”) took place on the 15 and 16 May 2018 and was unannounced. We carried out this inspection as a responsive comprehensive inspection due to concerns we had shared with us about the service. This included information from whistle blowers and following a review of our records in line with our intelligence monitoring. Details of how we monitor Adult Social Care Services that are registered with us can be found on our website at:

Our information raised concerns about the number of falls resulting in injury, medicine errors, how people’s continence care was being managed and moving and handling practices.

We were told there was not enough staff or the right equipment to meet people’s needs. Also, people’s medicines were not being fully signed for, people were not having their prescribed creams put on their skin and people’s continence needs were not being met. Staff were also not reading care plans so were unaware of people’s needs and preferences.

In addition, there were concerns about staff were not speaking to people, staff not wearing gloves and aprons as they should and staff were not passing concerns on to management and complaints were not being dealt with appropriately.

When we completed our previous inspection on 27 and 28 September 2017 we found concerns relating to staffing levels; gaps in medicine records; people’s care plans not fully reflecting their care; activities not being personalised and the provider was not ensuring the quality of the service. This meant we rated the key questions of Safe, Responsive and Well-led as Requires improvement. Effective and Caring key questions were rated as Good.

We requested the provider to tell us in an action plan how they were going to put right the concerns in respect of breaches of Regulations for staffing the service safely; assessing, monitoring and improving the quality of the service and in ensuring people’s records were complete and accurate.

Ashleigh Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Ashleigh Manor can accommodate 65 people in two separate parts of the premises. These are known as ‘The Manor’ and ‘The Lodge’. Historically, people in The Manor are living with dementia or complex needs and people of reduced complexity lived in The Lodge. However, on this inspection we found people had complex needs in both parts. When we inspected, there were 51 people living at the service. The Manor had 25 people living there and 26 in The Lodge.

A registered manager was not currently in place in respect of this service. However, the current manager was in the process of registering with us. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. They were supported in running the service by a care manager, two administrators and one of the registered partners/provider. One of the provider’s daughters acted on behalf of the registered provider during the inspection with the main partner/provider attending the second day of the inspection.

On this inspection, we reviewed the concerns we had received and checked to see if the provider was compliant following the last inspection. We found some improvements had been made in some areas but we also found continued concerns and some new concerns that are summarised below.

Staff described the lack of staff and equipment as the two main issues impacting on people.


Inspection areas


Requires improvement

Updated 8 August 2018

The service was not always safe.

The service was not staffed safely to meet people�s needs.

People�s oral medicines were safely administered; their prescribed creams however were not always safely managed.

Practices around fire safety needed some improvement.

People had risk assessments to keep them safe. Some additions were required to ensure all needs were recorded.

Staff would raise any concerns about how people were treated and felt these would be taken seriously.

People who were vulnerable were looked after by staff who were recruited safely.

People were kept safe by good infection control practices.


Requires improvement

Updated 8 August 2018

The service was not always effective.

Staff were not always being trained to ensure they were competent to carry out their role effectively.

The service had not ensured it had the equipment and facilities available to meet people�s changing needs in a timely way.

People�s hydration needs were not always met.

People�s nutritional needs were met.

People�s capacity to consent to their care was considered but staff had not always had the training to understand how this applied to their role.


Requires improvement

Updated 8 August 2018

The service was not always caring.

People were not always enabled to be in control of their care as there were not enough staff to meet their needs.

Staff did not always have the time to provide caring support.

People and their relatives spoke positively about the staff.

People were treated with as much dignity and kindness as possible at this time.


Requires improvement

Updated 8 August 2018

The service was not always responsive.

People�s records had been improved but still did not fully represent people�s current needs.

Staff were not reading the care plans due to the restrictions on their time leaving people at risk of inconsistent care.

Some people were not being supported to remain active.

People�s end of live care choices was not being recorded.

People and relatives were happy with the system of raising complaints and concerns.



Updated 8 August 2018

The service was not well-led.

People were not assured of safe and appropriate care due to a lack of robust quality assurance processes and associated systems of leadership and governance.

The provider did not meet the minimum requirement of completing the Provider Information Return at least once annually.

Staff felt unsafe to speak out about the service and staff morale was low.

People and their families felt they could approach the manager to make suggestions if needed.