Ashleigh Manor Residential Care Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our inspection in September 2022, we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant people’s needs were not always met.

The provider was previously in breach of the legal regulation in relation to person-centred care and good governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations.

This service scored 46 (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 always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People were not truly involved or seen as partners in their care. There was limited information to demonstrate how staff were engaging with people in understanding their rights, supporting them to have increased opportunities, or enabling them to make informed decisions. For example, managers were reviewing people’s care plans and risk assessments monthly. However, there was no information to indicate how people were supported to take part in these reviews, or to show how their views/wishes had been sought or used to inform their ongoing care and support.

While staff knew people well, the information provided to staff was inconsistent. Some care and support plans were not sufficiently detailed and contained minimal guidance for staff on how to care for people safely, according to their preferences and wishes. Staff often relied on verbal handover or familiarity rather than up-to-date records to guide care, increasing the risk of inconsistent practice. This contributed to a breach of regulations relating to person‑centred care and good governance.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

People received care from a range of appropriate health professionals to meet their individual needs and were supported to attend appointments as required. Support plans identified which professionals were involved in each person’s care and staff understood how and to whom they should escalate changes in people’s needs or how to make referrals to relevant health services.

However, care planning and risk management systems were inconsistent and not reliably translated into practice. Records showed gaps in care delivery, including failure to follow care plans for seizures, inconsistent monitoring of risks, and lack of clear escalation guidance. Medicines were not always administered safely, with incomplete records, gaps in administration and uncertainty among staff about how to use some medicines. Staff told inspectors they did not always read care plans and relied on verbal information, increasing the risk of poor continuity. Incident monitoring and audits had not identified the issues found at this assessment. This meant people were not always assured of safe, continuous or coordinated support they required. This contributed to a breach of regulations relating to person‑centred care and good governance.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to people’s individual needs.

Managers understood the importance of meeting people’s communication needs. Support plans identified each person’s preferred methods of communication and included information on how they should be supported to understand and access information effectively. This approach helped to ensure people’s communication needs were known and met in line with the Accessible Information Standard (AIS). The AIS is a framework, making it a legal requirement for all providers to ensure people with a disability or sensory loss can access and understand the information they are given.

However, the provider did not always provide people and their relatives with clear, accessible and up-to-date information about their care and support. Some relatives reported good communication and regular updates about their family member’s wellbeing, and staff demonstrated an open-door approach where families could ask questions. However, this was not consistent. Several relatives told us they were not routinely involved in care planning or aware they could access care records, which limited their ability to understand how care was being delivered.

Documentation within care plans did not always clearly guide staff, with missing or unclear information, duplication and inconsistencies reducing usability. In some cases, staff were unaware of key guidance, such as how and when to administer certain medicines. This meant information was not always shared effectively to support safe, coordinated, and informed care decisions. Although some improvements in communication had been made since the previous assessment, this remained an ongoing concern and contributed to a breach of regulations relating to person‑centred care and good governance.

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

The provider did not always listen to or fully involve people and those close to them in decisions about their care, although engagement had improved in some areas. Feedback from relatives varied. Some described positive experiences where staff listened and involved them in decisions, while others said they had to ask for updates or were not routinely included in care plan reviews. Opportunities for feedback were available, including meetings and informal discussions, and some relatives said concerns raised were acted upon. However, there was limited evidence to demonstrate how staff supported people to have control over their lives or how they were actively involved in decisions about the care and support they received. People were not routinely encouraged to share their views through regular reviews or meetings, which limited opportunities for them to engage with how support was planned and delivered. People were generally able to express concerns and felt able to talk to staff, and during the visit people told us, “I can talk to anyone” and “they listen to me.” However, systems to capture and embed feedback into care delivery were not consistently effective. As a result, people were not always fully involved as equal partners in their care.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

Managers explained how they worked with other professionals to ensure people had equal access to care and people were supported to access external healthcare professionals, where required.

However, we found although most people were able to access healthcare services when concerns were identified, inconsistencies in initial and ongoing assessments meant people’s needs were not always fully recognised, assessed, or reflected in their care and support plans. For example, pre-admission assessments did not consistently capture the level of support people required, resulting in care plans not always providing staff with sufficient guidance to meet their needs safely and effectively. In some cases, changes in people’s health and wellbeing, including signs of illness or deterioration, were not recognised or responded to promptly. Although staff made efforts to support people to access healthcare services and activities, this was not always delivered consistently. As a result, people did not always receive care and support tailored to their individual needs and circumstances.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

The provider did not always ensure people experienced consistent outcomes or care delivery reduced the risk of inequality, although there were some positive experiences. Feedback showed some people received compassionate and responsive care, with staff recognising individual needs and providing emotional support. However, other evidence showed variation in the quality of care people experienced, particularly due to inconsistent risk management, documentation issues and staff awareness of care plans. Concerns were identified in relation to dignity, such as people’s bedroom doors being left open and inappropriate handling of personal belongings. People’s experiences also varied depending on staffing pressures, with some relatives reporting people in communal areas were not always noticed or engaged. This meant people’s experiences and outcomes were variable. In addition, staff did not always receive the appropriate training required to ensure they had the knowledge and skills to support people effectively or recognise and respond to any inequalities or barriers people may face.

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The service did not always support people to plan for the future or ensure their wishes were clearly understood and acted on, although there were some early signs of improvement. End of life care planning required improvement across the service, with limited evidence of advance care planning or documented discussions about people’s preferences. In some care records, plans relied on intentions to gather information later rather than clearly recorded wishes. We found some care plans lacked sufficient detail about people’s long-term needs and outcomes, including escalation plans and monitoring arrangements.

Although staff engaged external professionals when needed and some improvements had been made to documentation, plans were not always kept up to date or reflective of people’s changing conditions. This meant people’s future care needs and preferences were not always fully considered or planned for effectively; this remained an area requiring improvement and contributed to a breach of regulation relating to person‑centred care and good governance.