Ashleigh Manor Residential Care Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We identified 6 breaches of legal regulations. The provider was in breach of the legal regulations relating to safeguarding, safe care and treatment, recruitment, training, premises and equipment, and governance. People were not always protected from the risk of avoidable harm. We identified concerns with the management of risks relating to people’s assessed needs; insufficient action had been taken to manage and mitigate known risks in relation to the management of falls, epilepsy, weight loss, skin integrity, dietary needs, and continence. People’s medicines were not always managed or stored safely. Systems and processes in place did not ensure that people received their medicines as prescribed. We found some people were subject to blanket restrictive practices; there was no system to review restrictive practices to ensure they remained the least restrictive option. This meant the provider could not be assured that any restrictions were or continued to be in a person’s best interests. People were not supported by staff who had been recruited safely or who had the skills and experience to meet their individual needs. People were not always protected from risks associated with their environment, as routine environmental checks and audits were not regularly taking place. The manager told us all accidents and incidents were recorded and reviewed monthly to identify any learning which may help to prevent a recurrence. However, we reviewed this information and found that it was not accurate. We have asked the provider for an action plan in response to the concerns found at this assessment. However, people told us they felt safe living at Ashleigh Manor and had confidence in the staff supporting them. Most relatives did not have any concerns about their loved one’s safety.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People who wished to share their views told us they felt able to talk to the staff if they had any worries. Comments included, “Yes, I can talk to the regular staff if I’m worried, which I have been,” “Yes, I do but never needed to,” “Yes, they are easy to talk to,” and “No concerns.” Relatives we spoke with told us they felt comfortable raising concerns about the service or their loved one’s care if they needed to do so. Comments included, “No, but I came close when her things which I’ve replaced have gone missing,” “Yes, if I have any niggles, I can raise them and they get sorted,” “Yes, I’ve complained about lots of things, mum’s care, dirty room etc,” and “Yes, I’ve mentioned missing clothes on several occasions and that I’ve seen another lady wearing her clothes.” However, we found where some relatives had raised formal concerns, the service had been slow to respond, marginalised their concerns, did not always accept responsibility for their actions or provide a sufficient response. We discussed what we found with the manager and provider, who agreed that the way in which the previous management team managed complaints was not in keeping with the provider’s policy and procedures.

The manager told us that all incidents, accidents, and concerns were recorded, reported, and investigated. This enabled lessons to be learnt and open and honest conversations with the staff team. They told us how they shared information with people and external agencies, such as healthcare professionals, when things had gone wrong, as well as liaising with families where appropriate to do so. Staff understood their responsibilities to document and report accidents and incidents in accordance with the provider’s policy and procedures and felt able to raise concerns with the management team when needed. Staff told us the culture in the service had been very different under the previous management team and had only improved in the last 5 weeks. One member of staff said, “I was accused of things that I had not done.” Another said, “I used to dread coming into work.” However, staff told us things were getting better, and they now felt able to speak up and raise concerns. Comments included, “The morale has definitely lifted 100%,” “It is much better now, but it definitely went downhill,” “It is a definite improving picture,” and “I feel comfortable with [senior management teams names] approaching them and feel confident if there was any issue, they would capably resolve things.”

The manager described the systems and processes in place to record accidents and incidents. The manager told us that each month this information was reviewed to identify themes and trends and identify any learning which may help to prevent a reoccurrence. We looked at this information with the manager and found it could not be relied upon as it was not correct. The provider had a policy and procedure for recording and reviewing complaints and compliments. However, we found this was not always being followed, nor was it seen as an opportunity to learn lessons and drive improvement. We discussed what we found with the provider, who told us the previous manager had not always shared information of concern with them. However, they told us they would now take the lead in reviewing complaint responses before they are sent out. The service’s development plan was not up to date at the time of the assessment and, as such, was not being used to capture outcomes or track improvements.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People consistently told us they felt safe living at Ashleigh Manor. Comments included, “Yes, so far so good, they keep an eye on me,” “Yes, I feel safe here, more than I did at home because there’s staff around if you need them. It’s reassuring that there’s someone to help,” and “Yes, I’m safe, but I want to go home. I feel like I’m in a prison – a nice prison, but I want to go home. I feel like a square peg in a round hole; I’m in limbo.” Relatives did not raise any concerns about people’s safety when asked. Comments included, “Yes, she is safe, but I worry about others coming into her room and lying on her bed. There’s also a person who gets stroppy,” “Mum doesn’t like it here, but I am more than happy with her care. I’m a District Nurse and know what to look for, and I visit 3-4 times a week,” “Yes, she is safe. I have no concerns about her care. I feel she’s in the right place as she is settled now,” and “Mum’s been permanent here since January this year, and yes, she’s safe – a few blips at the start, but all sorted. I’m happy with her care.”

The manager described how the service protected people from abuse along with the action they would take should they be made aware of any concerns about people’s safety. All of which was underpinned by the service’s policies and procedures. Staff had received training in safeguarding adults. They were aware of their responsibilities and knew what action to take should they suspect a person’s safety or welfare was at risk. One staff member said, “If I witnessed any abuse or had any safeguarding concerns, I would report it to the manager first of all and if they did not do anything, I would contact the safeguarding team directly and yourselves and, if needed, the Police,” Another said, “If I had any concerns I would tell Plymouth’s safeguarding team.”

During the assessment, we observed many positive interactions between people and staff. People appeared to have developed good working relationships with the staff supporting them. The staff were warm and engaging and spoke about people with respect.

There were systems in place to protect people from abuse, including policies and procedures and training for all staff. Prior to this assessment, we received information of concern relating to the use of restrictive practices, the circumstances of which are currently being reviewed by the Social Care Ombudsman Service. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is usually through the Mental Capacity Act 2005 (MCA) application procedures called the Deprivation of Liberty Safeguards (DoLS). We found some people were subject to blanket restrictive practices without a legal framework in place to support them. Some people living at the service had in place a door alarm and/or sensor to monitor their movement and whereabouts. We found these restrictions had not been processed in line with the Mental Capacity Act 2005 or the Deprivation of Liberty Safeguards code of practice. For example, staff had not completed a mental capacity assessment or followed a best interests decision-making process before applying the restrictions. There was no system in place for reviewing restrictive practices to ensure they remained the least restrictive option. This meant the provider could not be assured that any restrictions continued to be in a person’s best interests. The failure to provide care and support in line with the Deprivation of Liberty Safeguards code of practice was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s involvement in the development of their care and support varied due to their individual needs and wishes. Most people we spoke with were not aware of their care plan or associated risk assessments. However, one person, who was living at Ashleigh Manor temporarily, told us they had taken part in discussions about risks. They said, “Yes, I have had conversations about the risks of returning to my flat. I’m hoping to move back to my housing association flat, and I go back there to check on the work being done on my shower, which has to be completed before I return.” Relatives told us they were involved in their loved one’s care, and staff kept them informed of any changes. Comments included, “Yes, me and my sister are involved,” “Yes, I am and was involved in the discussion re her call bell set up,” and “I was involved in discussions re moving her into a different room because she was wandering at night. Now in a different room, which is better for her and safer.”

People were not always protected from the risk of harm. We identified concerns with the management of risks relating to people’s assessed needs. We found insufficient action had been taken to manage and mitigate known risks in relation to the management of falls, epilepsy, weight loss, skin integrity, dietary needs, and continence. We discussed what we found in relation to people’s skin with the Head of Care [HOC] from the ‘Lodge’. The HOC told us care delivery was overseen daily by themselves and team leaders. The team leaders completed a daily form documenting care tasks achieved. However, this form did not provide evidence that staff were checking people were being repositioned as they should, their mattresses were set at the correct levels, and staff had applied skin creams. The HOC confirmed there were no checks or oversight in place to make sure people received the care they needed. We spoke with the HOC from ‘the Manor’ about the lack of person-centred information and guidance in people’s care plans and risk assessments. The HOC told us that since they had returned to the service, they had identified care plans and risk assessments lacked detail and care plan reviews had not been happening. They told us they had a long way to go to address this, but they had made a start and re-written 5 care plans. However, we reviewed 1 of the reviewed care plans and found the care plan and risk assessments still lacked sufficient detail to ensure risks were managed and mitigated. We discussed what we found with the manager, who told us they were aware people’s care plans and risk assessments had not been reviewed in several months. They assured us following changes in the service’s senior management team, this had been identified and was being addressed.

People at risk of skin damage had appropriate pressure-relieving equipment in place, such as airwave mattresses and pressure-relieving cushions. However, these were not always set correctly. This meant people were potentially at risk of skin damage Sensor alarm mats were in place to alert staff where people had been assessed as at risk of falling. During the assessment, we observed staff supporting people to move safely

Systems and processes in place did not provide assurance that people were protected from the risk of harm. Risks to people's health and welfare had not always been assessed, and care plans and risk assessments were not always accurate and up to date. Care plans and risk assessments throughout the service lacked sufficient guidance about how to manage or mitigate risks, which potentially placed people at risk of harm. One person had been diagnosed with Epilepsy. There was no care plan in place regarding the management of this person's epilepsy or seizure activity. Staff had not been provided with any written guidance on how they should manage or mitigate these risks. Some people’s continence was being managed with a urinary catheter. Care plans and risk assessments did not contain sufficient information and guidance to manage and mitigate risks associated with their catheter. For example, there was no information guiding staff on how to care for the catheter, what to look out for that might indicate a concern and what action they needed to take. Risks associated with people’s diabetes were not being managed well. Staff were not always following instructions and guidance from health professionals on managing people’s blood glucose levels. Whilst care plans and risk assessments were in place, these did not always contain enough information to manage risks associated with their diabetes. For example, care plans lacked information about dietary needs or regular diabetic checks, such as specialist foot and eye care services. Risks associated with people’s skin were not always being mitigated and managed safely and/or in line with people’s care records. Records did not always demonstrate people were being repositioned according to their assessed needs. Records did not demonstrate staff were applying people’s skincare creams as prescribed for them. Whilst pressure relieving air flow mattresses were used for people at risk of skin damage, we found 4 mattresses were set too high and not set according to people’s current weight. This meant people were potentially at risk of skin damage as mattresses may be too hard for their skin. One person’s records indicated they were allergic to eggs, whilst staff we spoke with were aware of this allergy. Staff were not consistently checking this person was not consuming products containing eggs. This potentially placed this person at an increased risk of avoidable harm. The failure to ensure risks relating to the safety of people receiving care and treatment were appropriately assessed, mitigated, or effectively managed placed people at an increased risk of avoidable harm. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People did not raise any concerns about their living environment. Comments included, “Yes, it’s always kept clean, and you always see the cleaner around cleaning,” and “I’m untidy, and they respect it’s my room, and they clean around my bits and pieces.” We received mixed feedback from relatives about people’s living environment. Comments included, “Yes, since [Managers name] been back – it’s got better. Everything is being improved, modernised, and painted,” “Yes, it’s clean, and the building is safe. Lots of redecorating at the moment – it needed this as it was looking tired.” “No, the carpet in her room is filthy and matted with food,” “I’m aware of ripped wallpaper and the remains of Christmas decorations on the ceiling, there’s mismatched furniture,” and “The home looks shabby in places.”

The manager told us staff completed several environmental audits to monitor the safety of the environment and equipment. However, we found audits were not being completed. The nominated individual told us they were aware some aspects of Ashleigh Manor were still in need of some attention and assured us there was a plan in place to address these areas. For example, there was a plan in place to replace the conservatory roof within the ‘Manor’

Staff had left a kitchen door open in the ‘Manor’, adjacent to where people were sitting. Just inside the door, there was a kettle boiling. We asked the manager to take immediate action to address this safety concern. The kitchen door in the ‘Lodge’, which had a sign stating, ‘keep shut at all times,’ had been tied open with a plastic bag, again allowing access to recently boiled kettles. We intervened and asked the maintenance person to remove the tie and close the door. Windows throughout the service had not been fitted with a suitably robust tamper[1]proof restrictor to ensure compliance with health and safety legislation. Window restrictors had not been fitted correctly, as they did not restrict the window openings to 100mm or less. This meant people had been placed at an increased risk of harm as they potentially had access to window openings large enough to fall through. We brought this to the attention of the manager and asked them to take immediate action to ensure people’s safety. The failure to ensure people were protected from risks associated with their living environment placed them at an increased risk of harm. This was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Some areas of the service looked tired and in need of redecoration, and some areas were not clean. For example, we saw some equipment used to support people was not clean; a communal toilet was not clean and had various marks on the walls and ceiling. The bathroom on the lower and upper floors in the ‘Lodge’ was out of action due to refurbishment. The failure to maintain basic facilities to meet people’s needs meant people had to travel some distance through communal areas to receive personal care, potentially impacting people’s privacy, and dignity. On all 3 days of our site visits, we noted an unpleasant odour coming from the link corridors, which linked the ‘Manor’ to the ‘Lodge’. We discussed with both the manager and the nominated individual, who did not seem to be aware of the odour within the service. The failure to ensure the premises were suitably maintained for the purposes for which they are being used was a breach of Regulation 15 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were not always protected from risks associated with their environment, as routine environmental checks and audits were not regularly taking place, nor did they identify concerns we found during this assessment. For example, water temperature testing, window restriction and fire safety checks were not consistently completed. The failure to ensure people were protected from risks associated with their living environment placed them at an increased risk of harm. This was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There was limited dementia-friendly signage to support people in navigating their way around the home. We recommend the provider review the accommodation with regard to best practice guidance about creating a dementia-friendly environment and meeting the needs of people with a sensory impairment

People who were able to share their views told us there were enough staff to meet their needs. Comments included, “Yes, there are enough,” Yes, usually there are,” “Yes, always someone I can talk to,” “Yes, enough staff,” and “Sometimes there’s plenty of staff but not always.” However, we received mixed feedback from relatives regarding staffing levels. Comments included, “Yes, there are, but they do have to work hard. Sometimes short-staffed,” “Yes, I think there are, but Mum doesn’t. She says the bells are ringing all the time, so in her mind, staff are rushing and busy, so she doesn’t ring her bell,” “Sometimes there’s enough, sometimes not,” “To be honest, I’ve felt lately that they could do with more staff, especially at the weekends,” and “I think they have more than enough staff - always something going on and people flitting about.”

The manager told us there were enough staff to meet people’s needs safely. However, during the assessment the provider and manager were not able to provide us with a dependency tool to show how they determined staffing levels. This affected how the service assured themselves there were enough staff to meet people’s assessed needs. Staff told us staffing levels had improved, although they still used quite a bit of agency to cover shifts. Comments included, “It is much better now the old management team have left. I was a team leader down for a couple of months, which meant I was always on my own,” “I know they are currently taking people on and there has been so much agency used and I do not want to sound negative but agency staff do not know the residents,” and “Currently we do not have enough staff but [Managers name] is very much aware of that and the aim is to reduce our use of agency.” Staff confirmed they attended training but did not always receive regular supervision. Comments included, “I think we have done a lot of the online training,” “I have not had supervision, so it has been a bit up and down with all the management changes,” “I have had a mix of online training and we had in-person training as well so that was moving handling and infection control,” “I did a load of online courses to refresh so I think I am up to date but they normally let us know when we are due to do training online,” and “With supervision, I would say I had 1 with [previous manager’s name], but I can’t remember when nothing since then.”

Throughout the inspection, we noted people’s ‘call bells’ were constantly ringing. Whilst this did not necessarily mean there were insufficient staff to meet people’s needs, it was an indication of the high level of need within the service

People were not protected by safe recruitment practices. Prior to the assessment, we received concerns about how the provider recruited staff. We looked at the recruitment information for 8 staff members. Records confirmed a range of checks, including application, interview, and Disclosure and Barring Service (DBS) checks, were conducted before staff started working at the service. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. However, the provider had failed to carry out any recruitment checks in respect of the previous manager. Records for 3 staff who had recently been dismissed for gross misconduct by the provider and reemployed, did not contain any information to show the provider had considered the reasons for the staff’s dismissal. Or what action they had taken to mitigate any potential risks to people or staff arising from their dismissal and subsequent re-employment. Another staff member’s file contained information of concern relating to the reason for leaving their previous employer. There was no information contained within the staff member’s recruitment file to indicate the provider had either identified or explored the reasons for this. We also noted this person’s recruitment file did not contain a reference from that employer. The provider’s failure to establish and operate safe and effective recruitment procedures in accordance with Schedule 3 placed people at an increased risk of avoidable harm. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider monitored staff training on a training matrix. Records showed senior staff had received training in a variety of subjects relevant to their role. However, we could not be assured care staff had received the same appropriate level of training. For example, we found several care staff had not completed training in person-centred care, oral care, continence promotion, dignity, dementia, diabetes, epilepsy, mental capacity, and end-of-life care. We discussed what we found with the manager who said they recognised this was an area that needed to improve and had set up courses for November 2024 into the New Year. Records showed staff were not receiving regular supervision. We discussed what we found with the manager, who told us they had not been able to find any supervision carried out by the previous manager but were in the process of meeting with staff. This potentially placed people and staff at an increased risk of harm. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People we spoke with told us the service was clean and tidy, Comments included: “My room is nice and clean,” “Yes, it’s clean,” and “It’s definitely clean.” Most relatives did not raise any concerns about the cleanliness of people’s bedrooms. Comments included, “Her room always seems clean enough,” “Yes, we comment on how clean it is. Her loo is spotless,” “Yes, I’m very happy with the cleanliness. Her room is always clean, she is always clean and is wearing clean clothes,” and “The cleaning staff do a brilliant job.”

The housekeeper told us they had recently returned to the service, and at the time of the assessment, they were not sure of their role or what paperwork they would be required to complete monthly. They said the service employed 4 cleaners, a housekeeper, and a laundry person daily. Staff told us they had received training in infection prevention and control and had access to sufficient supplies of personal protective equipment [PPE] when needed. Throughout the assessment, we saw cleaners were constantly busy. However, we noted some areas remained in need of attention despite being cleaned. For example, we noted a communal toilet had unhygienic marks on the walls and ceiling, which remained after cleaning had taken place. We brought this to the attention of the manager and nominated individual, who immediately arranged for the maintenance person to decorate [paint] this area.

The provider had infection control policies and procedures in place and staff had access to personal protective equipment [PPE]. Staff received training in infection control and used PPE to help prevent the spread of infections. Regular audits and spot checks helped to identify areas for improvement. However, we found gaps in daily cleaning records, and infection prevention control audits were not consistently being completed. We noted some areas of the service and equipment used to support people were not clean, and there was an unpleasant odour coming from the corridors which linked the ‘Manor’ to the ‘Lodge’. The failure to maintain records to monitor the cleanliness of the service was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People who chose to share their views said staff supported them to take their medicines. One person said, “Staff let me know when it’s time to take my tablets.” Another said, “The girls [meaning care staff] are very good, they speak to the doctor, collect my tablets and bring them up to me.” Relatives did not raise any concerns about the management of people’s medicines. Comments included, “Yes, she gets her meds appropriately,” “Mum gets her meds - no problems,” “Yes, mum is compliant with her medication,” and “Yes, she is on strong drugs, staff liaise with the home’s dedicated GP who is exceptional.” However, we found people did not always receive their medicines as prescribed, nor were these given correctly in line with people’s prescriptions. Medicines were not always stored safely. We saw the lock to a cupboard used to store people’s medicines was broken. The cupboard was in the team leader’s office that was not locked, and the door was left open. Staff had not recognised that this placed people living at the service at risk and had not taken action to address this. We asked staff to take immediate action to address this during our visit.

We discussed the concerns we found in relation to medicines management with the heads of care for both units and the manager. The heads of care told us they were aware there were some issues with medicines management at the service and they had identified some errors. The head of care for ‘the ‘Lodge’’ told us they had started to audit one of their medicines trollies and had completed some medicines error forms. However, they were not aware of the concerns we had identified, including errors related to controlled medicines and unsafe medicines storage, which put people at risk. We discussed our concerns with the manager and provider and asked them to complete an immediate audit of controlled drug medicines (CD’s). We have shared our concerns with Plymouth City Council’s safeguarding team for further follow-up and review

People’s medicines were not always managed or stored safely. Systems and processes in place did not provide assurance people received their medicines as prescribed. Multiple medicines including controlled drug patches (CD’s), used for pain control and people at the end of their lives, were not always managed safely. Where people were having pain relief administered through a patch on their skin, records were not always in place to ensure these patches had been given as prescribed, applied correctly and the site of application was being rotated to protect people’s skin from becoming sore. Alterations to people’s prescriptions made by their GP were not always actioned by staff. For example, one person’s medicine dose had been increased on 24 September 2024 from 25mg to 50mg a day. Their medicines administration chart had not been updated, and the person had not received their increased dose for 13 days. Medicines administration records (MAR) for some people had been handwritten when the prescription had been altered by the person’s GP. However, handwritten MAR charts did not always contain the necessary information, such as the dose strength of the medicine and had not always been signed by 2 staff members to confirm the transcribing was correct. This is not in line with the National Institute for Health and Care Excellence’s guidance on ‘Managing medicines in care homes’. Some people did not receive their medicines when they needed them as staff had not made sure there was enough stock in place or ordered before it ran out. Guidance to support staff in the safe administration of ‘when required’ medicine, was not always in place. Where it was, guidance was general and lacked person specific information. Medicines administered via creams and liquids were not always dated once opened. This meant that staff might be giving people outof date medicines. The failure to store and manage people’s medicines safely and to keep accurate records relating to the management of people’s medicines was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.