Ashleigh Manor Residential Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question as requiring improvement. At this assessment, the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not ensure the delivery of high-quality care.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, person-centred care, dignity and respect, staffing, notifying CQC of significant events, displaying performance ratings, and good governance.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and needs of people and their communities.

There was limited understanding across the service about how to meet regulatory requirements and deliver high-quality support to older people, including those living with dementia. The provider had not created a culture where people were consistently valued; expectations were low, and there was a lack of purpose and meaning in people’s daily lives. The registered manager and nominated individual did not demonstrate sufficient insight into what it was like to live in the service or the impact this had on people’s dignity and emotional well-being, as detailed throughout this report.

While some relatives were satisfied with the care their loved ones received, this was not everyone’s experience. For example, relatives consistently raised concerns about personal care and clothing. Comments included, “Often she is in other people’s clothes that don’t fit, she looks like a bag lady.” “She’s in other people’s clothes, her clothes are lost, her false teeth have gone.” “Often her fingernails look grubby. Mum isn’t having showers; she is having strip washes.” “Staff are not paying enough attention to people sitting in wet clothing.”

The culture within the service did not ensure people were treated with dignity and respect. At the previous assessment, we found people’s basic right to privacy and dignity was not always understood or respected by staff. For example, staff frequently left bedroom doors open while people were in bed, people were wearing clothes that did not belong to them, and some people’s bedrooms were malodorous. This had not improved at this assessment.

Staff at all levels did not appear to understand the impact timely personal care and the environment had on people’s wellbeing, and concerns about people’s safety were not always escalated promptly, as detailed in the safe and effective sections of this report.

The failure to provide person-centred care and ensure people were treated with privacy and dignity contributed to breaches of regulations relating to person-centred care, dignity and respect, and good governance.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, or experience to lead effectively.

The registered manager and provider did not demonstrate sufficient oversight of the service to ensure people received care and support that promoted their wellbeing and protected them from harm. They did not identify the concerns we found at this assessment.

Although quality assurance systems were in place, they could not be fully relied upon to provide an accurate view of the service. They did not always consider all available information, contained inaccuracies, and lacked sufficient detail about what was being reviewed. This meant the provider did not have a clear and accurate understanding of the service, which limited their ability to identify concerns and make timely improvements.

Audits and checks carried out by the provider and manager could not be relied upon to measure the quality of the service or identify risks. This placed people at risk of harm because there was no assurance the leadership team understood all risks faced by people using the service or took timely action to address them.

There was a lack of understanding regarding how to meet regulatory requirements and deliver high-quality care and support to older people who may be living with dementia. This had led to a poor culture where people were not always consistently treated with dignity and respect.

Poor decision-making and judgments placed people at potential risk of harm. For example, in relation to risk management and safeguarding individuals from abuse.

Although policies and procedures were in place, they were not consistently followed. This included key areas such as care planning, risk management, medicines administration, safeguarding, and the application of the Mental Capacity Act 2005. This contributed to a breach of regulations relating to good governance.

Throughout the assessment, the senior leadership team acknowledged areas requiring improvement and expressed a commitment to address concerns and improve staff practice. They described plans to use feedback from the assessment to develop a comprehensive service improvement plan, strengthen governance arrangements, and improve the culture within the service.

The provider had policies in place to support staff to speak up, raise concerns, and keep people safe. For example, complaints and whistleblowing.

People consistently told us they were able to speak up and raise concerns if something was not right. Comments included: “Yes, all the carers are approachable. I had a pain in my chest, and I told them, and they called the paramedics in.” Yes, I mentioned to one of the carers today that six of my rings had disappeared from my room last night. I’ve not heard anything yet but won’t let this go.” “I speak my mind; I feel honesty is the best policy.”

Staff spoke positively about recent changes within the service and the new manager. They told us they felt able to raise concerns if needed, both internally and externally to the local authority. Comments included: “[Registered manager name] is very approachable.”

“I would go to [Housekeeper’s name]; she is brilliant and really nice to work for and will always put herself out for you.” “The registered manager, heads of care, and team leaders are really understanding and supportive, and you feel like you can go and talk to them.”

However, we received mixed feedback from relatives about their ability to speak up and effect meaningful change. Some relatives told us staff communicated well, they were able to raise concerns and were kept informed when things changed. One relative said, “They have let me know when mum’s not well.” Another said, “Really happy with this home. I cannot speak highly enough of them; they are all very approachable, we are very happy, they keep me updated about appointments and how he is.” However, other relatives were not positive; they told us communication was poor, and they did not feel listened to when they raised concerns. One relative said, “I did complain when Mum fell out of bed, but nothing happened.” Another said, “When I’ve complained to the manager, she just says they should have told you. Communication is an issue.”

The provider valued diversity within the workforce.

The registered manager told us they aimed to create an environment where staff felt treated with dignity and respect. They said the service did not tolerate bullying, harassment, or discrimination. The staff team was diverse, with a mix of genders, ethnicities, and backgrounds, and staff were made to feel welcome and accepted.

Policies stated recruitment decisions would not be based on ethnicity, sexual orientation, age, race, gender, disability, gender reassignment, or any other characteristic that could lead to discrimination. All staff were required to complete equality and diversity training. However, records showed that 30 out of 57 staff had not completed this training.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate.

Governance processes were not effective in keeping people safe, protecting their rights, or ensuring staff had the necessary skills to meet people’s individual needs. These systems failed to drive improvement, did not identify the issues highlighted during this assessment, and could not be relied upon to measure quality or manage risk. Concerns included failures in person-centred care, dignity and respect, safeguarding, staffing, consent, risk management, and the safe handling of medicines. For example, monthly falls analyses for March, May, June, July, and August 2025 recorded what had happened when people experienced a fall. However, the sections on ‘actions taken’ and ‘risk assessments/care plans updated’ were left blank. These records were incomplete and did not identify themes, trends, or learning. This placed people at risk of harm because the service had not identified how to prevent recurrence or support people with falls in a person-centred way.

The registered manager understood their responsibilities under the duty of candour, which requires providers to be open and transparent with people who use services and those acting lawfully on their behalf in relation to care and treatment. However, systems were not operated effectively to identify and report significant events. As a result, the provider did not notify the Care Quality Commission of 23 significant events, as required by law.

In addition, during a tour of the service, we noted the provider had not displayed the correct performance rating for the service, which is also a legal requirement.

The provider’s oversight and governance of the service had been ineffective in identifying and addressing failings in safety, quality, and standards, as detailed in the Safe, Effective, and Well-Led sections of this report. This contributed to breaches of regulations relating to notifying CQC of significant events, displaying performance ratings, and good governance.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people.

The registered manager recognised the importance of partnership working to improve outcomes for people. They described working closely with individuals, their families where appropriate, and the local authority. Records showed staff engaged with healthcare professionals, including GPs, district nurses, and the speech and language therapy (SALT) team, to support people experiencing eating and drinking difficulties. However, staff did not always follow the advice provided or escalate concerns to external professionals, as detailed in the Safe and Effective sections of this report.

Staff understood the value of working in partnership with people, families, and other professionals. However, concerns were not always raised or advice sought promptly. This impacted the quality of care provided and placed people at increased risk of avoidable harm, as documented in the Safe section of this report.

Some relatives told us they had not been formally asked for their views or invited to provide feedback, and many felt communication with the service was poor. One relative said, “They don’t inform us if there is a problem, if mum is not feeling well and has seen the doctor, we find out afterwards. When I’ve complained to the manager, she just says they should have told you. They are very slack at telling you things.” Another said, “I’ve never been to any meetings involving mum.” This contributed to the breach of regulation in relation to person-centred care and good governance.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcomes and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Governance systems were not effective in identifying shortfalls, monitoring quality, or driving improvements. For example, the service’s improvement plan contained limited detail about actions taken to address concerns raised at the last assessment and did not identify several issues found during this assessment. As a result, it could not be relied upon to monitor quality or support sustained improvement.

The provider had not demonstrated the ability to learn lessons or maintain improvements despite changes in the management team, investment in care planning systems, and external support. While regular meetings took place with staff at all levels, there was no clear evidence that staff recognised or addressed failings that impacted the quality and safety of the service.

Learning did not consistently take place following accidents and incidents. The provider had not developed a proactive learning culture where concerns about safety and quality were identified and addressed promptly and effectively. For example, the registered manager was not fully aware some relatives had raised concerns about their loved one’s care, meaning these concerns were not always acknowledged or acted upon in a timely way.

Feedback was not consistently sought from people or their relatives, nor was it used as an opportunity to support learning and improvement. Relatives told us they had not been asked for feedback, and communication with the service was described as poor.

This contributed to breaches of regulations relating to safe care and treatment, safeguarding, person-centred care, dignity and respect, and good governance.