Ashleigh Manor Residential Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, person-centred care, dignity and respect, staffing, need for consent and good governance.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing, and communication needs with them. At the last assessment, we found the failure to properly assess, develop and review people’s care and support was a breach of regulation in relation to person-centred care. At this assessment, we found not enough improvement had been made.

The provider had systems in place to ensure people’s needs were assessed before support was offered. However, senior staff told us discharge-to-assess arrangements under the ‘Trusted Assessor’ approach were not working effectively, as they did not always receive accurate or complete information prior to admission. This concern was also raised at the previous assessment, and the provider continued to not carry out its own pre-admission assessments.

Where assessments had taken place, we found information from these assessments were not always used to develop person-centred care plans, and some care plans contained minimal guidance for staff on how to care for people safely, as detailed within the safe section of this report.

Care plans did not always contain accurate or sufficiently detailed information about people’s care needs or risks. For example, in relation to verbal and physical aggression, falls management, skin integrity, weight loss, and nutrition.

There was limited evidence of meaningful involvement from people or their relatives in developing or reviewing care plans. While care reviews took place, they were not effective in identifying or addressing concerns found during this assessment. This was compounded by the staff’s limited ability to use and understand the new computerised care planning system.

This contributed to a breach of regulations relating to person-centred care, safe care and treatment and good governance.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Although support plans and risk assessments were in place to help ensure care was delivered in line with best practice guidance, they were not consistently followed. For example, risks to people’s skin integrity were not consistently managed in line with care plans and NICE (National Institute for Clinical Excellence) recommendations for pressure ulcer prevention. Records did not always confirm repositioning occurred as assessed or that prescribed skin care creams were applied. This placed people at an increased risk of skin breakdown and avoidable harm.

Pressure-relieving equipment was not always used safely for people at risk of skin breakdown. For example, one person’s pressure-relieving mattress was set to a weight range of 110–130 kg, while the most recent recorded weight in their care records was 68.6 kg. NICE guidance recommends pressure-relieving mattresses are set according to the person’s weight and checked regularly to ensure correct function. Incorrect mattress settings may reduce the effectiveness of pressure relief, increasing the risk of skin breakdown and avoidable harm.

Staff had not always been provided with appropriate training to ensure they were informed about and kept up to date with best practice guidance. Training did not always determine practice, and assessments of staff competencies could not be relied upon. [See the safe and effective staffing quality statement section of this report.]

The failure to provide safe care and treatment that met people’s needs and reflected their preferences contributed to a breach of regulation in relation to person-centred care, safe care and treatment, staffing and good governance.

Staff had a good awareness of people's dietary needs. Care records highlighted where risks with eating and drinking had been identified. Where people needed a specific diet, this was provided in line with their assessed needs.

Most people were happy with the food provided by the service. Comments included: “The food is very good. You get a choice of 2 meals at lunchtime.” “The food is always good. They always ask me what I fancy. I always thank them for the meals. I appreciate it,” and “I enjoy the food, it’s nice, and you can have seconds.” However, some people were not happy with the quality of the food. Comments included: “The food is not to be recommended, we don’t get a choice, we get the same meals every day, and it’s a lot of cheap food,” “Yuck, it’s tasteless on the whole,” and “I don’t like the sandwiches, the bread can be old and dry.” Relatives did not raise any specific concerns about people’s nutrition or hydration needs.

The provider did not always work well across teams and services to support people.

The provider had systems and processes in place to effectively share information about people with the local hospital, their GP practice and primary care health services. However, we found staff at all levels did not fully understand how to use the computerised care planning system, which had been introduced following the last assessment. This meant information was not readily available and limited staff’s ability to share important information with external professionals.

Records showed staff supported people to attend a range of healthcare appointments, including dentists, opticians, GPs, and the older persons’ mental health team. Staff told us they reported concerns about people’s mental and physical health to the management team and made referrals to healthcare professionals when needed. Senior staff said regular handovers were used to share information about people’s health needs. However, concerns were not always identified or escalated promptly. For example, records for one person showed they lost 15.8% of their body weight between February and August 2025. A review of care records for the previous 12 weeks did not show any evidence of escalation or referral to healthcare professionals in response to this weight loss.

Care plans and risk assessments did not always provide detailed information about individuals’ changing needs or contain clear guidance for staff on how to manage them. For example, senior staff told us one person was receiving end-of-life care. However, we found there was no end-of-life care plan in place.

We received mixed feedback from relatives about the staff’s ability to meet their loved ones’ needs. Positive comments included: “Mum has got bed sores. They got the district nurse out and she’s looking after them,” “They do get the doctor in,” and “The home fought to get mum prescribed incontinence pants, which they did; so now she can do it herself and I don’t have to buy them”. However, some relatives were not positive, comments included, “Mum lost her NHS dentist as they didn’t take her to the appointment,” “They took Mum to hospital, that’s when they noticed the bed sores; they could see they had been there a few weeks. The district nurse is happy they are healing now,” and “Mum was going for an appointment this week for a pre op before an operation. They said they were going to take her, but what actually happened is that she was sent on her own in a taxi, the taxi driver then sat in reception while she went in on her own. She has full dementia. If I’d have known, I would have gone with her, but nobody told me.”

The failure to work in partnership to provide care and treatment that met people’s assessed needs and reflected their preferences contributed to a breach of regulation in relation to safe care and treatment, person-centred care, and good governance.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or, where possible, reduce their future needs for care and support.

People were encouraged and supported to engage with a range of healthcare services. For example, they were supported to access GPs, district nurses, and attend scheduled appointments. Information from these appointments was mostly recorded in care records, helping staff understand people’s healthcare needs. However, people did not always receive timely support to manage their personal care needs. For example, some people were not supported promptly with continence care. Staff at all levels did not appear to notice, and there was a lack of understanding about how this affected people’s dignity and well-being. Delays in continence care can leave people feeling uncomfortable, exposed, and at risk of embarrassment, which undermines their dignity and may negatively impact their emotional well-being.

We received mixed feedback from relatives about the support their loved ones received. Whilst relatives consistently told us staff were kind and doing their best, they did not always have confidence in the staff ability to meet their loved ones’ personal care needs. Comments included, “Mum has support stockings which should be taken off every day and her legs washed and moisturised, but that’s not happening.” “When I visit, I see mum’s hair is filthy and greasy, never clean.” “Care checks are not being done.” “Mum had shoes that were made specifically for her. They cost £200, and they have gone missing. It means we can’t take her out anywhere.”

The failure to provide support to meet people’s assessed needs contributed to a breach of regulation relating to person-centred care and dignity and respect.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. At the last assessment, we found the provider had failed to establish and operate effective systems to monitor people’s health and care needs. At this assessment, we found not enough improvement had been made.

The provider had systems in place to ensure people’s care and support was continuously monitored and reviewed to promote good outcomes for people. However, staff did not always support people in line with their assessed needs, and reviews did not consistently take into account all available information. For example, information recorded following incidents was not used to update people’s care plans or inform staff practice. This represented a missed opportunity to identify and mitigate risks.

Care reviews did not identify any of the concerns we found in relation to person-centred care, the management of risk, accidents and incidents and mental capacity.

People and their relatives were not consistently involved in identifying care needs or reviewing care. Care plans were not easily accessible, and there was limited evidence of meaningful involvement in developing care and support. One relative said, “I have never been involved in any meetings about mum.” Another said, “She has a care plan, but I’ve not seen it.”

This contributed to the breach of regulation in relation to person-centred care, safe care and treatment and good governance.

Following the introduction of the new care planning system, senior staff had implemented a care review system. However, we found this process needed more time to fully embed, as changes identified were not always made in a timely manner.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

At the last assessment, we found the provider’s failure to properly assess and record people's capacity and best interest decisions risked compromising people's rights and contributed to a breach of regulation in relation to the need for consent. At this assessment, we found not enough improvement had been made.

We reviewed a selection of mental capacity assessments and found some documentation was poorly completed and continued to show a lack of knowledge, understanding and application of the principles of the Mental Capacity Act 2005 (MCA). For example, some mental capacity assessments did not contain any information about how people were being supported to understand, retain, weigh up information, or communicate their decision.

The provider had policies and procedures in place to support people in understanding their rights. The registered manager and senior staff spoke about the importance of obtaining consent and following the principles of the MCA. However, this knowledge was not consistently applied in practice. While some documentation relating to capacity assessments and best interest decisions was informative and of good quality, other people had not had their capacity assessed, nor had staff followed a best interests process. For example, 3 people received their medicines covertly as part of their planned care arrangements. Their capacity to consent to this approach had not been assessed, and care records did not demonstrate decisions were made in line with MCA principles.

People were not consistently supported to make decisions about their care. Some staff demonstrated limited understanding of their responsibilities under the MCA, including the Deprivation of Liberty Safeguards (DoLS). As a result, decisions for individuals who lacked or had fluctuating capacity were not always made in accordance with legal requirements. For example, the provider submitted DoLS applications to the local authority without first assessing whether people had the capacity to consent to these restrictions, and the provider was unable to provide evidence a best interests decision-making process had been followed.

The continued failure to properly assess and record people's capacity and best interest decisions risked compromising people's rights. This contributed to a breach of regulation relating to the need for consent, person-centred care, dignity and respect, and good governance.