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 inadequate. At this assessment, the rating has remained inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The provider was previously in breach of the legal regulation in relation to safe care and treatment, safeguarding, person-centred care, dignity and respect, staffing, need for consent and good governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations.

This service scored 33 (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 provider failed to properly assess, develop and review people’s care and support. At this assessment, we found not enough improvement had been made.

The provider had made improvements to its assessment processes; however, these changes had not yet been fully embedded in practice at the time of this assessment. As a result, there remained a risk, people could receive care and support that was not appropriately planned, responsive to their needs, or delivered safely.

Care records and pre-placement assessments did not consistently reflect people’s current needs and risks. For example, one person who had recently been admitted to the service had an incomplete care plan, with only 3 sections completed. In addition, the pre-admission assessment completed before their arrival did not fully reflect information provided by the hospital before discharge, which identified significant risks relating to falls, self-neglect, and the need for full support. This meant there was a risk staff would not have access to accurate and comprehensive information to guide the delivery of safe and effective care.

Whilst most people had assessments and risk profiles in place, these were often generic, duplicated or not tailored to the individual. Staff told us care was often delivered based on verbal handover rather than written care plans, and relatives’ involvement in care planning was inconsistent. For example, care plans also contained conflicting information, such as people assessed as independent despite known risks including malnutrition, communication barriers or continence issues.

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 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; this continued to expose people to the risk of avoidable harm. At the last assessment, we found the provider failed to provide safe care and treatment that met people’s needs and reflected their preferences. At this assessment we found some improvements had been made, but they were not consistently embedded.

Although tools and clinical inputs were used, such as MUST, SALT guidance and specialist input from nurses, care delivery was not always consistent with these plans. For example, staff did not always follow epilepsy protocols, and there was a lack of clear guidance for emergency medicines, with staff unsure how or when to administer them.

Risk management was inconsistent. While risk assessments were present, they were often generic, duplicated or not updated following changes in people’s needs. Staff practices did not always reflect known risks, including failure to act following incidents such as falls or medical device concerns. The ongoing failure to provide safe care and treatment in line with best practice or evidence-based guidance 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.

Some good practice was observed, including use of specialist dietary guidance. 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.

The provider did not always work well across teams and services to support people. At the last assessment we found the provider failed to ensure staff worked in partnership to provide care and treatment that met people’s assessed needs and reflected their preferences. At this assessment, we found improvements were still needed.

The provider had systems and processes to effectively share information about people with the local hospital, their GP practice and primary care health services. There was evidence of multidisciplinary involvement including district nurses, GPs and specialist teams, and professionals provided positive feedback about their engagement with the service. One healthcare professional said, “There have been several positive changes since their last inspection, and we have confidence in the staff and management team.”

However, this was not consistently translated into practice. Care plans did not always reflect guidance from professionals, and changes in people’s needs or care were not always communicated effectively to staff. Staff told us they were not routinely alerted to updates in care plans and relied on verbal handovers instead.

Internal communication systems were inconsistent. Training gaps, incomplete induction processes and ineffective supervision meant staff were not always supported to deliver coordinated care. Records showed supervision and training did not consistently address competency or practice issues. This contributed to a breach of regulation in relation to safe care and treatment, person-centred care, and good governance.

Although teamwork between staff was described positively and some improvements in governance had been introduced, systems were not robust enough or fully embedded to ensure people received consistent, coordinated care and treatment met their assessed needs and reflected their preferences.

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. At the last assessment we found the provider’s failure to provide support to meet people’s assessed needs contributed to a breach of regulation relating to person-centred care, dignity and respect. At this assessment, while we found improvements had been made and some people experienced positive outcomes, improvements had not had time to be fully embedded.

People generally had access to sufficient food and fluids, where required tailored support was provided, including fortified diets, monitoring of weight and escalation to health professionals when concerns were identified.

There was also evidence of meaningful activities and social opportunities, which had improved, and some people and relatives described positive experiences, such as “she’s always doing something – skittles, singing… brilliant.”

However, this was not consistent across the service. Some people’s health needs were not always identified promptly, including issues relating to hygiene, skin integrity and early signs of deterioration. Care records did not always evidence clear health monitoring or escalation, and environmental risks such as unsafe water temperatures and fire safety concerns impacted people’s overall wellbeing.

The service had taken steps to improve activity provision and aspects of care, but these improvements were not yet embedded or consistently experienced by all people.

The provider did not routinely monitor people’s care and treatment to continuously improve it.

They did not ensure outcomes were positive and consistent, or they met both clinical expectations and the expectations of people themselves. At the last assessment, we found the provider did not always routinely monitor people’s care and treatment to continuously improve it. At this assessment, we found improvements were needed as the provider did not have effective systems in place to monitor and improve outcomes, and this continues to result in widespread and repeated failures.

There was evidence of a “tick box” culture, where documentation was completed without ensuring practice had changed. Care plan reviews frequently recorded “no changes” despite evolving risks. For example, staff did not always have sufficient information to support people in line with their assessed needs, and reviews did not consistently consider all available information.

Systems were not yet embedded and did not provide assurance people were receiving safe, high-quality care. This contributed to an ongoing breach of regulation in relation to person-centred care, safe care and treatment, staffing and good governance.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment. At the last assessment, we found the provider’s continued failure to properly assess and record people's capacity and best interest decisions risked compromising people's rights. At this assessment, we found not enough improvement had been made.

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, 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.

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. Examples included the use of covert medicines without appropriate assessments, restrictions on visits without evidence of best interest decisions, and decisions about moving people or implementing care interventions without consultation or consent.

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.