Ashleigh Manor Residential Care Home

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• 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

We identified 3 breaches of legal regulations. The provider was in breach of the legal regulations relating to person-centred care, need for consent, and governance. People were not always supported to have maximum choice and control of their lives, and staff did not fully understand their roles and responsibilities under the Mental Capacity Act 2005 (MCA), including Deprivation of Liberty Safeguards (DoLS). People’s care had not been planned with them, and care plans were not sufficiently detailed to enable staff to provide safe, appropriate care which met people’s needs and preferences. Care plans and risk assessments were not being regularly reviewed or updated when people’s needs changed. Whilst the provider did have systems and processes in place to monitor and improve outcomes for people. These were not effective as checks were not taking place.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most people were not able to tell us if they had taken part in an assessment of their needs before receiving support. However, people expressed confidence in the staff that supported them. Comments included, “I wish I could get carers like these so I could go home, but I can’t get them,” “The regular staff know my routine,” and “Yes, I feel safe here, it’s reassuring that there’s someone to help.” Relatives confirmed they had taken part in the assessment process and felt fully involved in the care and support planning process. Comments included, “Yes, they do their very best and try very hard. They know mum likes to dress herself; they know this may take 2-3 hours; they respect this.” “Yes, I did sit with her and the home and did a questionnaire about her likes/dislikes. They are aware of her needs.” “Yes, I believe so. They phone me if they’ve made a referral like for a hearing test and continence assessment.” Yes, I do get phone calls and updates.”

The manager told us people's needs were assessed before they started using the service. Information from these assessments were used to develop care plans and risk assessments. These were reviewed regularly and audited by senior staff as part of the provider’s governance processes. However, we found reviews had not taken place for several months. We discussed what we found with the manager who explained since their return to the service 5 weeks ago, they had identified care plan reviews had not been happening and there was a plan in place to address this. Staff told us, the current arrangements with the local hospital to take DTA placement [discharge to assess patients from hospital to adult social care services] under the ‘Trusted Assessor’ approach were not working as well as they could have. They did not always have access to information about people’s needs prior to their arrival and the information provided could not always be relied upon as it was not always accurate or reflective of the person’s needs, and the service did not carry out their own assessment.

The provider had systems and processes in place to help ensure all people’s needs were fully assessed prior to offering support. However, we found these were not always followed. Information from these assessments was used to develop individualised care plans which covered all aspects of a person’s life. However, we found that whilst there was a clear system in place to develop and review people’s care, care plan reviews had not taken place for several months. This meant care plans and risk assessments were not always reflective of people’s needs and lacked essential guidance for staff. Please see the safe section of this report, ‘Involving people to manage risks’, for more information. The provider told us that due to personal circumstances, they had not visited the service as often as they would have liked and were not aware care reviews were not taking place. The provider had not taken any action to address concerns expressed by senior staff in relation to the timeliness or quality of the assessments provided by the hospital under the discharge to assess scheme [DTA’s]. The failure to address concerns expressed by senior staff meant neither the provider nor manager could be assured they were able to meet a person’s needs before they were admitted. The failure to properly assess, develop and review people’s care and support was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us they enjoyed the food provided by the service. Comments included, “I enjoy all the food – no complaints at all. Today’s roast was nice,” “I’m very happy with the food – I’ll eat anything,” “The food was all right today. It went to pot for a while. It’s improved in the last couple of weeks. Today we had real chicken not reformed chicken, and it was tasty,” and “I’m vegetarian, and they respect that with the food I have.” We received mixed feedback from relatives about people’s experiences. Comments included, “She’s well fed, gets a choice of food, and has no complaints at all,” “Mum is not a fussy eater or a big eater, but she will try anything,” “She likes the food; food is important to mum. She’s disappointed that they’ve tweaked the menu recently as there’s no fish and chips now on a Friday,” and “I’m told she’s eating well.” However, some relatives were not so positive. One relative raised concern about food going missing from their mother’s room. Other comments included, “I don’t think they should just plonk mums’ food in front of her and walk away and expect her to feed herself. Also, sweets go missing from her room,” and “Sometimes there’s no alternative to the meal of the day.”

Staff knew people’s likes and dislikes and appeared to have a good awareness of people's dietary needs. However, care plans did not, in some cases contain clear information about people's preferences. Care records highlighted where risks with eating and drinking had been identified. Where people needed a soft or bite-size diet, this was provided in line with their assessed needs and senior staff were knowledgeable about the extra support that some people might need to maintain nutrition and hydration. We saw examples of where staff had sought additional advice and support from SALT [Speech and language therapy] following a change in people’s needs. However, we found specialist advice was not consistently sought, nor did it always form part of the person’s care plan. Staff were knowledgeable and there was clear information about people’s allergies, but there was no process in place to ensure people were not offered or received foods that may contain a product to which they were allergic. For example, one person had an allergy to eggs. However, we found foods in this person’s room containing eggs.

Systems were in place to ensure care was delivered in line with best practice guidance. For example, nationally recognised risk assessments were used to assess risks, such as the Malnutrition Universal Screening Tool (MUST) and Water Low Risk Assessment. However, we found these records were not being regularly reviewed or kept up to date as people’s health needs changed and did not contain sufficient information to mitigate risks. Where people were at risk of poor nutrition, their weight was not being regularly monitored. Records showed staff had made referrals to healthcare professionals for support and advice. However, this information did not always form part of the person’s nutritional care plan. Staff had received training in food hygiene but not specifically in relation to nutrition and hydration. The failure to provide safe care and treatment that met people’s needs and reflected their preferences was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

People received support to manage their health and physical care needs and were encouraged to engage with a range of healthcare services. Relatives had confidence in the staff and told us their loved ones were supported to manage their care, support and health needs by staff who knew them well. Comments included, “Mum has regular appointments with the GP and Nurses. When Mum had a fall, they called the ambulance straight away and kept me informed,” “They arrange for dad to have regular check-ups with the dentist and doctor when needed,” and “They are very responsive to Mum’s needs, they arrange all her appointments and let us know so that we can attend.”

Staff described how they supported people to manage their health and well-being to maximise their independence, choice, and control, but recognised there were times when people might need more support, such as with making and attending appointments. Staff confirmed they had access to people’s support plans but told us they did not always contain up-to-date information about people’s needs. One staff member said, “People’s care plans and risk assessments are not up to date.” Another said, “We all know the care plans need some work, but we always have a handover, and if I have been off, I would go to the office, and they let me know if anything has changed.” As identified within the ‘involving people to manage risks’ and ‘assessing people’s needs’ section of this report, whilst it was clear staff knew people well, some care plans lacked detail and were not being updated following reviews with health care professionals. For example, 1 person’s care plan stated they could walk short distances with their walking frame. However, we found this person was being cared for in bed and was no longer able to walk. The manager was aware people’s care plans were not up to date or reflective of their current needs and assured us there was a plan in place to address this.

Systems and processes were in place to effectively monitor people’s health and well-being. Records confirmed staff supported people to attend a range of appointments with dentists, opticians, and GPs. However, whilst staff understood people’s needs, care plans and risk assessments did not always provide detailed information about individuals' health needs or clear guidance for staff on how to manage them. Regular handovers enabled the sharing of information about people’s health needs.

People who wished to share their views with us spoke positively about the support they received. Comments included, “The regular staff know my routine, but the agency staff don’t know what to do,” “Yes, they are all very sociable – at home I was lonely but not since coming here,” and “We’ve had fun with (Activities organiser name) playing a quiz, I was almost in tears as we laughed so much.” We received mixed responses from relatives about people’s experiences. Most relatives were positive about the care and support people received. Comments included, “Yes, I’m happy with her care overall and have confidence in them,” “Yes, they always ask her what she wants to do, they never force her,” “Yes, they are kind and nice, a couple of them know she likes fresh fruit so they bring her some,” “Yes, I’ve explained to them how to best communicate with her given that she’s deaf. They know she likes to lipread and to use little writing pads on her table to communicate with them and them to her. It works very well.” However, some relatives expressed some concerns about people’s overall experience living at the service. Comments included, “Staff seem a bit task focussed rather than person[1]centred,” “A lot of people, including my mum, are always sat in the lounge, and I get the impression this makes it easier for the staff to monitor the wanderers.” “Mum’s hygiene is poor, not sure if she’s bed-bathed or showered. She has faeces under her fingernails. My sister has mentioned this to them,” and “Yes, the permanent staff are good, the bank staff don’t know the ins and outs of the residents. Some of the bank staff assume she has dementia when she doesn’t.”

The manager and staff described how they monitored people’s health and care needs to ensure risks were mitigated and people received care according to their assessed needs. For example, staff described how they monitored people’s skin for red marks, applied prescribed creams, helped people reposition at regular intervals to relieve pressure and escalated concerns to the management team and/or external healthcare professionals as needed. However, we found skin creams were not always being applied as prescribed; repositioning records did not evidence people were being repositioned according to their assessed needs. Care records contained limited information about what was in place to minimise risks relating to some people’s pressure area care and, in some cases, contained conflicting information about the frequency of repositioning. Staff had a good understanding about how people communicated and used this knowledge to support people to make choices about their everyday needs.

Whilst the provider did have systems and processes in place to monitor and improve outcomes for people, these were not effective as they were not taking place. For example, MUST, falls, mobility, and nutrition assessments, etc. were not being regularly reviewed and in many cases, were outstanding since August 2024. Care plans and risk assessments were not being regularly reviewed and updated when people’s needs changed. Regular meetings with people and their relatives where appropriate, staff and external professionals were not taking place, and there was limited information about how the service was supporting people to be involved in their care or encouraged to provide feedback. The failure to establish and operate effective systems to monitor people’s health and care needs was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People who were able to share their views with us told us they felt safe and were able to make their own day-to-day decisions. Comments included, “I can choose when I go to bed, no set time,” “Yes, they know I like to have some knitting in my bag to do. I’m knitting baby clothes for my great-grandchild,” “Yes, they know I like to do some things for myself,” and “Always respect my choices. They know I like to vape outside when I can.” Relatives consistently told us they were involved and consulted about their loved one’s care. Comments included, “Yes, me and my sister are involved.” “No, her son does this as he’s POA [Power of Attorney].” “I’m involved, but mum makes her own decisions as she doesn’t have dementia,” And “Yes, I am. Mum had five infections earlier this year, one after another, and we discussed an end-of-life [EOL] package for Mum just in case. She refuses to go to the hospital, and I agree with this as her POA.”

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 that, 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. The manager and staff told us they had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS), and whilst they described the importance of obtaining people's consent and following the principles of the Mental Capacity Act. We found this knowledge and understanding was not applied consistently. For example, some people's care records did not always show their consent and/or views had been sought in relation to decisions being made on their behalf or that people were always being supported and empowered to have maximum choice and control over their lives

People were not supported to make decisions about their care and staff did not fully understand their roles and responsibilities under the Mental Capacity Act 2005 (MCA), including Deprivation of Liberty Safeguards. This meant people who lacked capacity or who had fluctuating capacity did not always have decisions made in line with current legislation. For example, where restrictions had been placed on people to keep them safe through the use of constant supervision or preventing them from leaving the service, this was not recognised by staff as restrictive practice, and people’s capacity to consent to these arrangements had not been assessed nor had staff followed a best interests process. Where the service had submitted DoLS applications to the local authority for consideration, people’s capacity to consent had not always been assessed prior to these applications being made; the service was unable to provide evidence that they had followed a best interests process. Mental capacity assessments and best interest decisions showed a lack of knowledge and understanding of the principles of the MCA. For example, some people’s MCAs did not contain sufficient information, were not person-centred and did not contain the views of the people consulted regarding the decision. We also noted that consent forms completed by the staff were not fully completed and, in some cases, had been signed on behalf of a person by their ‘Next of Kin [NOK]. NOKs are not legally able to provide written consent on behalf of someone who lacks capacity [unless they have a legal basis for doing so]. The failure to properly assess and record people's capacity and best interest decisions risked compromising people's rights. This was a continued breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had a clear policy and process in place to help ensure people were supported to understand their rights. Records showed, and staff confirmed they had received training in safeguarding adults, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).