Ashleigh Manor Residential Care Home

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Inadequate

• Caring

  Good

• Responsive

  Good

• Well-led

  Inadequate

Our view of the service

Date of assessment: 05 September 2025 to 24 September 2025.

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, 61 people were living at the service.

This was a responsive assessment carried out to follow up on enforcement action taken during our previous assessment in April 2024. The purpose was to check whether the Warning Notice served in relation to Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. We reviewed 21 quality statements. Our assessment identified 9 breaches of legal requirements in relation to safeguarding, safe care and treatment, need for consent, person-centred care, dignity, staffing, notification of incidents, failure to display performance assessment 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. The service did not focus on promoting people’s quality of life; care delivery was not always person-centred, and the culture did not reflect best practice for supporting people living with dementia. This meant people were at risk of receiving care and support that did not promote their well-being or protect them from avoidable harm.

The management team had not created an open and transparent culture where constructive feedback was encouraged. Relatives knew how to make a complaint but were not confident their concerns would be addressed.

At this assessment, the overall rating has changed from requires improvement to inadequate. This service is being placed 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, if the action has been taken forward. In addition, we have asked the provider for an action plan in response to the concerns found at this assessment.

People's experience of this service

We spoke with 16 people living at the service and gained feedback from 12 relatives to help us assess and understand how people’s care needs were being met.

People who wished to share their views with us told us they felt safe and were happy living at Ashleigh Manor. Comments included. “This is a good place to be, I feel safe and looked after.” “Yes, lovely, and safe here, good security and the door is always locked, and the carers keep an eye on me.” “The carers are lovely, kind, and helpful.” “The carers are absolutely lovely,” and “The people who work here are special.”

We received mixed feedback from relatives about their loved ones’ care and support. Positive comments included “Her bedroom and bathroom are spotless,” “Staff are always very kind and friendly,” “She’s safe as she can’t wander, I can go home with total peace of mind, it’s wonderful,” “I feel my mum is safe to the best of anyone’s ability,” “Staff definitely know what they are doing.” “Generally, she looks well cared for,” and “They are looking after my brother very well; he always looks clean and shaved.”

However, some relatives were not complimentary. Comments included, “Sometimes they don’t always pick up the phone, sometimes the alarm bells are ringing and ringing.” “It’s not the cleanest of places, the floors and around the bins. It can be very cold in winter; you go in, and all the residents are sitting with big throws on them.” “Staff will come in, say I will be back in a minute, and don’t come back for an hour. “Generally, we are concerned that they don’t have the training that’s needed.” “She’s in other people’s clothes, her clothes are lost, and her false teeth have gone,” and “The laundry system is not very good; all her woollies have been ruined in the tumble dryer.”

Although many people told us they felt happy, we found the service was not always operating in accordance with regulations and best practice guidance. People’s care was not always delivered in line with their assessed needs. While most staff knew people well and understood how to communicate effectively, people were not consistently treated with dignity and respect.