Ashleigh Manor Residential Care Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment, we rated this key question requires improvement. At this assessment, the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

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

This service scored 25 (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 have a proactive and positive culture of safety. They did not always identify, investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Theprovider had not developed a proactive and positive learning culture in which concerns about safety and quality were identified and responded to promptly and robustly. There was limited information to indicate the provider had learnt lessons from previous assessments or embedded good practice. At the last assessment, we found the provider had failed to effectively operate systems to identify, assess and mitigate risks associated with the health, safety and welfare of people using the service. At this assessment, we found improvements had not been made. For example, the systems in place to review accidents and incidents were not reliable, as the information used to identify themes, trends, and learning was inaccurate. We found several incidents had not been included in the provider’s monthly analysis because senior staff and the registered manager were unaware they had occurred.

The service’s development plan contained limited information on the action taken to address concerns raised during the last assessment and failed to identify concerns and shortfalls we found during this assessment; as such, it could not be fully relied upon to monitor the quality of the service or effectively drive improvements.

The provider’s failure to effectively operate systems to identify, assess and mitigate risks associated with the health, safety and welfare of people using the service placed people at an increased risk of avoidable harm. This contributed to a breach of regulation in relation to safe care and treatment, safeguarding, person-centred care, dignity and governance.

Most people who were able to share their views with us told us they felt safe living at Ashleigh Manor. One person said, “Yes, lovely, and safe here, good security and the door is always locked, and the carers keep an eye on me.” Another said, “I’m safe, no trouble at all – everyone gets on fine.” However, some people did not feel safe living at the service. One person said, “I’m not sure, we’re not particularly well looked after as there are too few staff, and they have too much to do. If an emergency happens, which it does quite often, we’re left alone.” Another said, “It’s ok, but I don’t like people going in my room.”

We received mixed feedback from relatives about people’s safety and experience. Whilst relatives did not raise specific safety concerns, some relatives were not happy with the standard of care provided to their loved ones. One relative said, “Is my father safe? I’m not certain, I’m not sure they have their eye on him.” Another said, “Honestly, when mum was first admitted there, I was aware that it didn’t have a great reputation. She is quite happy and settled there, and I believe it when the staff say they really like her. In an ideal world and lots of money, I would think she needs to go somewhere nicer.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

We found robust assessment processes were not in place to ensure a safe and smooth transition between services to reduce the risk of avoidable harm to people. Some care records lacked sufficiently detailed information and guidance for staff to ensure people received the health support they needed promptly. Care records did not include important information and guidance from assessments completed prior to people being admitted to the service. For example, in relation to the management of epilepsy. 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.

Senior staff told us about the current arrangements with the local hospital for discharge-to-assess placements under the ‘Trusted Assessor’ approach were not working effectively. They did not always receive accurate or complete information about people’s needs before arrival, and the information provided could not always be relied upon. This was the same information shared with us at the previous assessment, and the provider continued not to carry out its own assessments before admission. This increased the risk that people’s needs may not be identified or met, which may compromise their safety and well-being.

This contributed to a breach of regulation in relation to safe care and treatment and person-centred care.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Systems and processes had not been established or operated effectively to investigate immediately upon becoming aware of any allegation or evidence of abuse. Governance arrangements and provider-level scrutiny of safeguarding did not identify the concerns we found during this assessment. This placed people at risk of abuse and improper treatment. For example, staff recorded 3 incidents that involved sexualised behaviour between June 2025 and September 2025, where 2 people had potentially placed themselves at the risk of harm through exploitation or exposure to retaliation by their own actions. These incidents were not reported as safeguarding concerns to the Care Quality Commission, nor were they escalated to the management team within the service or to the local authority safeguarding team, as required by the provider’s safeguarding policy. As a result, investigations did not take place, and actions to mitigate risks and prevent further harm were not implemented.

Incident records showed between June and September 2025, there were 18 incidents where people had hit each other. None of these incidents had been reported to the local authority’s safeguarding team or to the Care Quality Commission. Incident records and care plans for each person contained insufficient information on any action taken by staff to reduce the risk of recurrence or protect people from harm. None of these incidents formed part of the registered manager’s accident and incident audit.

Staff had received training in safeguarding adults. They were aware of their responsibilities and knew what action to take should they suspect a person’s safety or welfare was at risk. However, staff did not always escalate their concerns to external agencies in line with the providers’ policy and their training. Furthermore, we noted 23 out of 57 staff had not completed safeguarding adults training. This placed people at risk of harm as they were supported by staff who may not identify, report, record, or act on suspected abuse appropriately.

The failure to effectively establish and operate systems to investigate and report allegations of abuse placed people at an increased risk of avoidable harm.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

At the last assessment, we found some people were subject to blanket restrictive practices without a legal framework in place to support them. At this assessment, we found improvements were still needed; despite additional training, the management team did not have a good understanding of the Mental Capacity Act (MCA) or Deprivation of Liberty Safeguards (DoLS). For example, staff had submitted DoLS applications for 2 people, which were not linked to their support plans or risk assessments, and staff had failed to complete mental capacity assessments or follow best interests decision-making processes before applying these restrictions.

The continued failure to effectively establish and operate systems to investigate and report allegations of abuse and to provide care and support in line with the Deprivation of Liberty Safeguards code of practice contributed to a breach in regulation in relation to safeguarding, person-centred care, the need for consent and good governance.

Most people told us they felt safe. Comments included, “Yes, lovely, and safe here,” “Yes, I am looked after here, I’m reasonably happy and feel safe,” “This is a good place to be, I feel safe and looked after,” “I feel my mum is safe to the best of anyone’s ability.” and “I’m safe, no trouble at all – everyone gets on fine.” However, we received mixed feedback from relatives about their loved ones’ care and support. Comments included. “It’s ok apart from when she went in, she could walk, now she can’t; she’s just sat there in a chair all the time,” and “Mum fell and broke her hip trying to get out of bed at night. They rang me at 3 in the morning. I had mentioned that the bed was too high.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At the last assessment, we found the provider’s failure to ensure risks relating to the safety of people receiving care and treatment were appropriately assessed, mitigated, or effectively managed had placed people at an increased risk of avoidable harm. At this assessment, we found improvements had not been made.

The provider’s ongoing failure to take adequate steps to address concerns relating to the management and mitigation of risks meant people continued to be exposed to the risk of avoidable harm. For example, we found insufficient action had been taken to manage and reduce known risks relating to falls, weight loss, skin integrity, verbal and physical aggression, epilepsy, and the use of pressure-relieving equipment.

Care plans and risk assessments throughout the service were not always accurate or up to date and lacked sufficient guidance about how to manage or mitigate risks, which potentially placed people at risk of harm. For example, one person had been diagnosed with Epilepsy. There was no care plan or risk assessment in place to support staff in delivering effective epilepsy care.

While some incidents were reported and reviewed, care records were not consistently updated to reflect the outcomes of these incidents or the action taken to reduce the risk of recurrence and protect people from harm. Staff had not been provided with any written guidance on how they should manage or mitigate these risks.

People’s involvement in the development of their care and support varied according to their individual needs and preferences. However, most people we spoke with were unaware of their care plans or associated risk assessments. There was limited information to show people were involved in reviews or that care plans were accessible.

Relatives told us staff did not actively involve them in the care planning or review process. Comments included: “She has a care plan but I’ve not seen it,” “I saw the care plan today, and it is incomplete as there is no rehab plan in place,” “You say something, and someone takes a note of it, nothing happens and when you ask again staff say ‘well, there’s nothing in his notes’, it seems to be how it goes there,” and “A risk assessment still hasn’t been done, I’ve been told 4 or 5 weeks wait; surely they should provide an interim ‘just in case.”

The provider’s continued failure to ensure risks relating to the safety of people receiving care and treatment were appropriately assessed, mitigated, or effectively managed placed people at an increased risk of avoidable harm. This contributed to breaches of regulation in relation to safe care and treatment, person-centred care, and good governance.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. At the last assessment, we found the failure to ensure people were protected from risks associated with their living environment placed them at an increased risk of harm. At this assessment, whilst some improvements had been made, people remained at risk.

Incident records showed in August 2025, one person fell down 5 steps in the ‘Lodge’. While staff sought medical advice, they did not consider or address the wider environmental safety concerns.

During our tour of the service with the housekeeper, we found the door to the laundry in the ‘Lodge,’ which led onto a steep concrete staircase, was unlocked and posed a serious safety risk. The housekeeper told us this had been the case for over a week. We asked the manager to take immediate action to address this concern.

The provider had not fully addressed fire safety concerns identified during a fire officer’s visit in June 2025. At the time of the assessment, the registered manager told us all actions had been completed; however, we found several actions were still outstanding. For example, fire doors were wedged open throughout the service, a large amount of combustible material remained stored adjacent to the kitchen, and fire door sets had not been properly tested or maintained. In addition, 19 staff had not completed fire awareness training, and 3 night staff had not received any practical fire training, including evacuation procedures and the use of fire safety equipment. These failures increased the risk of serious harm to people in the event of a fire and demonstrated non-compliance with fire safety requirements.

The provider’s failure to identify and act on environmental hazards placed people at an increased risk of avoidable harm and demonstrated ineffective risk management. This contributed to breaches of regulation in relation to safe care and treatment, and good governance.

People did not generally raise concerns about their living environment. However, a number of people told us the service was cold. One person said, “I need some heat in my room as I’m so cold, and that’s why I’m wearing all these clothes.” Another said, “My bedroom is cold, that’s why I am down here.” It was also noted by the inspection team that some aspects of the service were not warm, and people were wearing blankets. We brought this to the attention of the housekeeper, who told us the heating had just been turned on.

We received mixed feedback about the environment from relatives. Positive comments included “Her bedroom and bathroom are spotless,” “Her room was ok and clean, the TV wasn’t working but they fixed that,” and “Mum has a beautiful room, and they clean it every day.” However, some relatives were not complimentary about the environment. One relative said, “It can be very cold in winter; you go in, and all the residents are sitting with big throws on them. The roof leaks very badly in the conservatory.” Another said, “My father’s room is not suitable, there is a big door into the toilet, and there are no bars or a riser on the seat. They have found an old riser, and the staff who put it in told me the pins were hard to adjust as they were rusty.”

The provider had invested in the service and taken action to address some environmental concerns identified at the last assessment, October 2024. For example, window restrictors were now in place, a new commercial tumble dryer and cooker had been purchased, and plans were in place to repair the leaking conservatory roof, which was affecting people’s living space. In addition, several corridors and communal areas had been repainted, improving the overall environment for people using the service.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. At the last assessment, we found the failure to deploy sufficient numbers of skilled staff to meet people's assessed needs contributed to a breach of regulation in relation to staffing. At this assessment, we found not enough improvement had been made.

Staffing levels were not planned or deployed in a way that met people’s specific health care needs or ensured their safety. Throughout the assessment, we observed staff were consistently busy and did not have time to support people promptly with personal care or spend time engaging with them. We noted a lack of staff presence within the ‘Manor’, which may have been influenced by the layout of this area. For example, each time we walked through this part of the service, we had to locate a member of staff to assist someone who was calling out for help.

We were not assured 4 staff on duty at night was sufficient to meet people’s assessed needs or to keep them safe in the event of an emergency. This shortfall in staffing increased the risk people would not receive timely support during urgent situations, such as a fire or medical emergency, and compromised their safety and well-being.

We discussed staffing with the registered manager, who told us they used a dependency tool to determine staffing levels based on people’s assessed needs. However, they acknowledged the tool did not specifically calculate night-time staffing requirements. We reviewed the provider’s dependency tool and found it was not reflective of people’s needs at night. It did not consider staff breaks, time required to complete care records, additional night-time tasks, or the impact of emergencies when staffing would be reduced. This meant the provider could not be assured night-time staffing was sufficient to keep people safe and meet their needs.

People who were able to share their views with us said there were not enough staff to meet their needs. Comments included, “No, not enough to keep an eye on the wanderers and the women who shout at each other in the lounge or in the corridor. There’s one lady who just walks all day till she drops,” “Not really enough, some keep an eye on me,” “No, generally not enough staff,” and “I’m not sure, we’re not particularly well looked after as there are too few staff, and they have too much to do. If an emergency happens, which it does quite often, we’re left alone.”

Relatives consistently told us staff were kind and doing their best; however, they felt there were not enough staff to meet their loved ones’ needs, particularly at weekends. Comments included, “Sometimes they don’t always pick up the phone, sometimes the alarm bells are ringing and ringing,” “Staff are rushed off their feet, so maybe there are not enough staff at times,” “There is never someone in the dining room. Sometimes there can be 8 residents in there, and there should be someone keeping an eye on them”, “Staff will come in, say I will be back in a minute, and don’t come back for an hour.” “At weekends, they employ a lot of international staff who don’t speak English. They are also a skeleton crew; there is nobody there who is senior. You ask a question, and they don’t know anything; they didn’t even know Mum had dementia.”

Most staff we spoke with did not raise concerns about staffing levels. However, some night staff told us there were not enough staff on duty at night to meet people’s needs safely and complete all required tasks. One staff member said, “There is so much to do, there was an incident when we had to call an ambulance out, and 1 of us had to stay with the resident, and that leaves the other person to do everything else, and things are not done as they should be.”

The provider monitored staff training through a training matrix. Records showed significant gaps in essential training, including catheter care, continence, communication, dignity, dementia care, epilepsy, personal care, pressure area care, oral care, end-of-life care, and nutrition and hydration. Where staff had completed training, this did not always determine safe practice. For example, senior staff failed to act in accordance with the Mental Capacity Act and did not escalate concerns to protect people from harm. These gaps and failures increased the risk that people would not receive safe, effective, and person-centred care.

Records indicated staff were not consistently receiving regular supervision. Where supervision had taken place, it was not used effectively to assess ongoing competence or to address specific concerns. Additionally, there was no documentation to confirm annual appraisals had been carried out. The registered manager told us all staff completed an induction and did not work unsupervised until they had been assessed as competent to do so. However, some induction records were incomplete and did not show, competencies had been formally assessed prior to working unsupervised.

We received mixed feedback from relatives regarding staff competencies. Positive comments included: “Staff definitely know what they are doing,” “They seem to me well-trained and can communicate ok. Mum is hoisted now, and when I’ve seen it, they are very good, interactive,” And “Staff are competent as far as I can tell.” However, some relatives expressed concerns. Comments included: “Generally, we are concerned that they don’t have the training that’s needed.” When I ask questions, they are not able to answer,” and “The girls [staff] are all nice, but I have never seen staff sitting and talking to people, there’s no interaction with the residents.”

Thefailure to deploy sufficient numbers of skilled staff to meet people's assessed needs contributed to a breach of regulation in relation to staffing, safe care and treatment, and good governance.

People told us they had confidence in the staff supporting them. One person said, “Yes, they are competent, and I feel they do a good job. When they wash me, they check me for sore areas and cream me if necessary, and I don’t feel rushed.” Another said, “Yes, the staff are trained and helpful. I don’t need help with personal care.”

At the last assessment, we found the provider had failed to operate safe recruitment procedures. At this assessment, we found improvement had been made and the provider was no longer in breach of the regulation relating to recruitment.

Records confirmed that a range of checks, including application, interview, and Disclosure and Barring Service (DBS) checks, were conducted before staff started working at the service. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider did not always assess or manage the risk of infection. At the last assessment, we found the failure to maintain records to monitor the cleanliness of the service was a breach of regulation in relation to good governance. At this assessment, we found not enough improvement had been made.

Records showed most staff had received training in infection control, the control of substances hazardous to health (COSHH), and the use of personal protective equipment (PPE). Staff reported that PPE was readily available. However, we saw some staff did not consistently wear PPE when interacting with people or serving food.

Prior to the assessment, a relative had raised concerns with the local authority regarding the cleanliness of their loved one’s mattress, specifically, excessive staining. The housekeeper told us, as part of the service’s response to this concern, all mattresses were checked and replaced where necessary with washable / wipe-down mattresses. We checked a selection of mattresses with the housekeeper and found 3 mattresses which were heavily stained and had not been replaced. We noted some areas of the service and equipment used to support people were not clean, and there was an unpleasant odour of urine coming from the corridors which linked the ‘Manor’ to the ‘Lodge’, and some people’s bedrooms smelt of urine. We discussed what we found with the housekeeper, who told us there was no plan in place to address this.

Records used to monitor the cleanliness of the service and the maintenance of equipment were not sufficiently detailed. For example, checks for equipment and wheelchair safety were signed off as completed on a weekly or monthly basis, but there was no information about which items had been checked or what actions had been taken. This lack of detail meant the provider could not be assured equipment was safe and cleaning standards were consistently maintained.

We received mixed feedback from relatives about the cleanliness of the service. Positive comments included: “Her bedroom and bathroom are spotless,” “All the communal areas are clean,” and “When you go into her room, it’s always clean.” However, some relatives raised concerns about the standard of cleanliness and malodour within the service. Comments included, “There is always a smell of urine as you walk through various places,” “It’s not the cleanest of places, the floors and around the bins,” and “The smell of urine when you open the door is overwhelming.”

The provider’s failure to assess and mitigate risks and follow best practice guidance in relation to infection prevention and control placed people and staff at an increased risk of avoidable harm. This contributed to a breach of regulation in relation to safe care and treatment, person-centred care, dignity and good governance.

Throughout the assessment, we saw cleaners were constantly busy, and there were cleaning structures in place which covered all aspects of the service. All of which was overseen by a housekeeper. Following the assessment, the housekeeper shared with us a number of new checklists that would be introduced following our feedback.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. At the last assessment, we found the failure to store and manage people’s medicines safely and to keep accurate records relating to the management of people’s medicines was a breach of regulation in relation to safe care and treatment and good governance. At this assessment, we found not enough improvement had been made.

People’s medicines were not always stored safely. For example, medicines awaiting return were left on the office floor in the ‘Lodge’ and ‘Manor’, allowing access to people, staff and potentially visitors. We noted, both doors to the ‘Manor’ office were left open and unattended on several occasions throughout the assessment. We asked the registered manager to take immediate action to address this safety concern and ensure medicines were stored safely and securely to prevent unauthorised access.

People who were prescribed anticoagulant medicines, which increase the risk of internal bleeding if they fall, did not have a risk assessment in place with guidance for staff on what to do in the event of a fall or how to escalate concerns to healthcare professionals. This lack of guidance placed people at significant risk of harm.

One person was prescribed rescue medicines for Chronic obstructive pulmonary disease COPD and epilepsy; however, we found the MAR charts were unclear, and there were no protocols or guidance in place for staff on how and when to administer these medicines. This lack of clear instruction placed the person at risk of not receiving timely and appropriate treatment in an emergency.

Some people were prescribed medicines to be given when required (PRN). Protocols were in place to guide staff on when to administer these medicines; however, they did not contain sufficient detail to ensure medicines were given consistently and safely. For example, where people were prescribed variable doses, PRN protocols did not provide clear guidance on how much medicine staff should administer.

Some people were prescribed topical creams to protect their skin. Medicine Administration Records (MARs) showed these were not always applied in line with prescribing instructions. For example, one person was prescribed Epimax 3 times a day. MARs showed no creams were applied on 14 September 2025, and only applied once between 9 and 18 September 2025. The failure to follow prescribed instructions placed the person at risk of skin breakdown, as creams intended to protect their skin were not administered as required.

Systems were in place to audit medicine management, and records were maintained to document when medicines were administered or refused. However, these audits did not identify or address the concerns we found during this assessment. This meant the provider could not be assured that medicines were managed safely.

The continued failure to store and manage people’s medicines safely and to keep accurate records relating to the management of people’s medicines contributed to a breach of regulation relating to safe care and treatment, person-centred care, and good governance.

People who were able to share their views with us and their relatives did not raise any concerns about how medicines were managed. Comments included: “They sort out all her medication, no problem,” “No problems with her medication,” and I’m not sure what medication he takes, the staff sort that out, but I am not aware of any problems.”