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 inadequate. At this assessment, the rating remains inadequate. This meant, despite improvements, there continued to be widespread and significant shortfalls in leadership. Leaders and the culture they created did not ensure the delivery of high-quality care.

The provider was previously in breach of the legal regulation in relation to safe care and treatment, safeguarding, person-centred care, dignity, 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 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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service did not always have a shared vision, strategy and culture that ensured safe, person-centred care. While staff described an open culture with supportive management and said they were “happy to work here,” this was not consistently reflected in practice.

Although there had been some improvements since the last assessment, such as increased family engagement and activity provision, the provider continued to demonstrate a task-focused culture where improvements were not fully embedded. Governance records and care plan reviews showed a “tick-box” approach, with risks identified but not always acted upon or reviewed effectively.

People and relatives gave mixed feedback. Some relatives described compassionate care and improvements, with one stating staff were “kind, caring and polite,” while others raised concerns about staff being too busy and care not always responsive to needs. Continued breaches relating to dignity, person-centred care and consent demonstrated the provider’s values were not consistently translated into practice.

The ongoing failure to provide person-centred care and ensure people were treated with dignity and valued as partners in their care contributed to breaches of regulations relating to person-centred care, dignity and respect, the need for consent and good governance.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The service did not always have capable and effective leaders to ensure high-quality, safe care. There had been some positive changes in leadership, and staff and professionals described managers as approachable and supportive, with an “open door policy”.

However, leaders did not consistently identify or address risks. Assessment findings showed ongoing concerns with care planning, medicines, staffing, and environmental safety had not been recognised through management oversight. Although senior staff demonstrated knowledge of regulatory requirements, this was not consistently applied in practice, particularly in relation to the Mental Capacity Act and safeguarding.

Policies and procedures were not consistently followed. There were also gaps in staff training, supervision and competency assessment, and induction processes were not robust. Records showed missing training, inconsistent supervision and incomplete induction documentation, which limited leaders’ ability to ensure staff had the skills required. While some improvements had been made, leadership oversight remained ineffective and had not yet driven sustained improvement.

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. Following the assessment, the provider told us they had engaged an external consultant who would be supporting them in the development of an action plan to drive change within the service.

The service did not always ensure there was a culture where people and staff felt fully confident to speak up and be listened to. Staff told us management were approachable and responded to concerns, and some staff said they felt supported when raising issues.

The provider had policies to support staff to speak up, raise concerns, and keep people safe. For example, complaints and whistleblowing. However, governance systems did not consistently demonstrate concerns raised were acted upon or led to improvement. Supervision records showed staff raising concerns about care quality, staffing and cleanliness, but there was limited evidence of follow-up action or resolution.

Feedback from relatives was mixed. Some felt comfortable raising concerns and said managers were responsive, while others reported issues had to be repeatedly raised before action was taken, particularly regarding personal care and environmental issues. These inconsistencies meant people and staff could not always be assured their concerns would result in meaningful change, and improvements were not consistently embedded following feedback. This contributed to a breach of regulation relating to good governance.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service did not always ensure an inclusive and well-supported workforce could meet people’s needs effectively. Staff described working in a supportive team and said colleagues were “happy to help and guide” them. However, workforce systems were not robust. Training records showed significant gaps in mandatory training. Induction processes were inconsistent, and some staff were not included on training systems.

Staff feedback highlighted inconsistencies in knowledge and training, particularly in relation to mental capacity and care planning. Staff often relied on verbal handovers rather than updated records, which increased the risk of inconsistent care.

While some staff had developed strong relationships with people and provided compassionate support, the lack of consistent training and oversight meant the workforce was not always equipped to meet people’s diverse and complex needs safely and effectively.

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.

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.

The provider did not have effective governance systems to ensure safe, high-quality and sustainable care. Governance processes were not robust and failed to identify widespread concerns found during the assessment.

Although audits, checks and new systems had been introduced since the last assessment, these were not consistently completed, lacked detail, and could not be relied upon to provide an accurate picture of the service. For example, medicines audits and care plan reviews did not identify significant issues, including unsafe medicines practices, gaps in risk management and failures in care planning.

There were ongoing and repeated breaches relating to risk management, person-centred care, safeguarding, staffing and governance. This demonstrated the provider had not learned from previous assessments or embedded improvements.

People were exposed to risks because systems did not consistently identify or mitigate risk relating to people’s care and support needs, people’s human rights, the environment, and medicines management. This contributed to a breach of regulation relating to good governance.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

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 and maintained links with the local community. Health professionals, including district nurses and GPs, provided positive feedback about the service and were involved in people’s care. There was evidence of multi-disciplinary involvement in care planning, including input from specialists such as SALT and nurses, and staff supported people to access healthcare when needed.

Relatives were often kept informed about changes in people’s health, and some described being actively involved in care decisions and reviews. One relative said, “They phone me with every single thing,” reflecting good communication in some cases. However, this was not consistent across the service, as other relatives reported limited involvement in care planning and difficulty accessing information. This meant partnership working was variable and not always embedded across the service.

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.

The service did not always demonstrate effective learning and continuous improvement. While some improvements had been made since the last assessment, these were not consistently embedded or sustained.

Systems designed to learn from incidents, audits and feedback were not fully effective. Accident and incident reviews did not consistently lead to updates in care plans or risk assessments, and audits failed to identify key issues in areas such as medicines, care planning and safety.

Care records and audits indicated a pattern of ‘tick box’ compliance rather than meaningful learning, with repeated issues across assessments. This showed the provider had not consistently used information to drive improvement.

Although staff described efforts to improve care, including updating care plans and increasing activities, the lack of effective oversight and follow-through limited the service’s ability to achieve sustained improvement. This contributed to breaches of regulations relating to safe care and treatment and good governance.