Ashleigh Manor Residential Care Home

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• 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

We identified 1 breach of legal regulations. The provider was in breach of the legal regulation relating to governance. At the time of this assessment, the service did not have a registered manager. The provider’s oversight and governance of the service were ineffective in identifying the serious failings in relation to the safety, quality, and standard of the service as detailed in the safe, effective, caring, and responsive sections of this report. The provider did not demonstrate an understanding of the regulations or the legislation underpinning the regulations. Governance processes were not effective in keeping people safe, protecting people's rights, providing good quality care and support, or driving improvements. Poor judgements and decision-making had led to a closed culture within the service where staff felt unable to speak out or raise concerns due to the fear of losing their jobs. Systems and processes to engage with people, their relatives, visitors, and health professionals to obtain feedback about the service and share learning were not taking place. Throughout the assessment, the management team were open and honest, acknowledged any areas of concern, and were keen to make improvements. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The manager described how the present senior team had all left the service under the previous manager due to the poor culture within the service and had returned 5 weeks before our site visit. They said they had been responsible for the previous rating and were determined to make the necessary improvements. One member of the senior management team said, “It was heartbreaking to see what we used to have in place and how we worked to get things in place and to come back to what we came back to is heartbreaking.” Another said, “We just don’t know if things were done or where they are.” It was clear from our conversation the manager and staff were passionate about achieving the best outcomes for people. The manager was aware of their responsibilities in relation to the duty of candour, that is, their duty to be honest and open about any accident or incident that had caused or placed a person at risk of harm. Staff told us the culture in the service had been poor, they were not able to speak out for fear of retribution by the previous management team, and they did not feel supported by the provider. Comments included, “I loved my job, but I used to dread coming into work,” “I was accused of things that I had not done,” “It was not a nice time to be here,” and “You were afraid to speak up. I had to keep my mouth shut.” However, staff spoke more positively about the current management team. Comments included, “They should never have got rid of them [senior management team names] the morale is better, and things feel so much better”, “It is much better now 100%.They listen and are much more approachable, their door is always open,” and, “It is getting a bit better now, and we might be getting back on track, and staff are coming back.”

The provider did not demonstrate an understanding of the regulations or the legislation underpinning the regulation. As such, we were not assured the providers had the necessary skills and knowledge to provide safe care and treatment. The provider’s failure to demonstrate leadership through safe and effective recruitment placed people at risk of avoidable harm. For example, the previous manager of the service had been appointed without any recruitment checks taking place. Poor judgements and decision-making by the provider had led to some members of staff being dismissed and reemployed without fully understanding the reason for the dismissal or identifying what action, if any, should be taken to mitigate any potential risks with their re-employment. Policies and procedures supported an open and inclusive culture where staff at all levels of the organisation were encouraged and supported to ‘speak up. However, we found the lack of oversight by the provider had enabled the development of a closed culture within the service where staff felt unable to speak up or raise concerns for fear of losing their jobs. We discussed what we found with the provider, who told us due to personal circumstances, they had taken their eye off the ball. They accepted some of their decision-making during this time was not as robust as it should have been and acknowledged this had been a contributory factor to the failings we found at this assessment. The service did not have a manager registered with the Care Quality Commission at the time of the inspection. The provider had appointed a previous manager to oversee the service. At the time of the assessment, they had applied to become the registered manager for the service. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We found audits and spot checks had not taken place for several months, and there was limited evidence to support meetings taking place or to demonstrate provider oversight. We discussed what we found with the provider, who said that due to personal circumstances, they had not been able to visit the service as often as they would have liked, and they had not been aware the former manager was not completing audits and spot checks. The provider and manager described the systems and processes in place to monitor the service and ensure compliance with the regulations. The provider told us each month the manager carried out a range of spot checks and audits to monitor the quality and safety of the service and ensure compliance with the regulations. For example, management care floor observation, general observation of shift, mealtime observation, mealtime observation audit tool, staff observation form, individual daily records (room care plans), residents’ daily life audit, resident care plan audit, medicines, safeguarding, accident and incidents, recruitment, training, health and safety and the environment. The manager told us regular handovers and staff meetings helped to ensure essential information about people's care needs was shared within the staff team and/or escalated, if needed, to other healthcare professionals. In addition to the auditing process, the provider told us they held regular meetings with the manager to discuss the service, staff, and people. This enabled them to identify any concerns, agree on actions, and monitor progress on existing action plans.

Governance processes were not effective in keeping people safe, protecting people's rights, and ensuring staff had the necessary skills to meet people’s needs. This meant they did not drive improvement and did not identify the issues we found at this assessment. Issues included concerns with the management of people’s medicines, management of risks relating to people’s care and the environment, safe recruitment, mental capacity, DoLS, and training. The provider had not ensured staff understood the principles of the MCA. This lack of knowledge and understanding risked compromising people's rights. Systems were not fully embedded into practice or robust enough to demonstrate accidents or incidents were effectively monitored, reviewed, or used as a learning opportunity. The provider’s oversight and governance of the service had been ineffective in identifying the serious failings in relation to the safety, quality, and standard of the service as detailed in the safe, effective, caring, and responsive sections of this report. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Throughout the assessment, the provider and manager acknowledged the service was not where it needed to be and were keen to address any areas of concern.

The registered manager recognised the importance of working in partnership to improve people’s outcomes. They described how they had previously worked in close partnership with people, their families where appropriate and the local authority to achieve good outcomes for people. Staff described how they worked in partnership with the district nurses who supported people with skin conditions such as pressure ulcers, the SALT team [speech and language therapist] to support people who may be experiencing eating and drinking difficulties, and the older person’s mental health team [OPMHT] who provided support for some people living at the service who had advancing Dementia

We received no specific feedback from partner agencies prior to this assessment taking place. The local authority quality assurance team were working with the service following some changes in the management team. We did not receive any information of concern from health professionals involved with the service prior to the assessment taking place. Following the assessment, we discussed what we found with the local authority, who told us they had confidence in the current manager and were working with the service to develop a service improvement plan.

Systems and processes were in place to show how the provider worked in partnership with key stakeholders. Some care plans demonstrated the service actively engaged with people and their families and sought support from a range of healthcare professionals. This meant advice and support could be accessed as required. However, we found this information did not always form part of people’s planned care arrangements. Systems were in place to gather people's, relatives, and staff’s feedback on the quality of the service and used to measure the service’s performance and drive improvements. However, we found these had not been completed since 2023, and the result of these could not be relied upon to provide a true reflection of the service.

People spoke positively about the service, the staff, and the management team. Comments included, “Yes, they are lovely and caring,” I’m quite happy with them.” “The staff always have a smile and say hello, everyone has been lovely.” Relatives had confidence in the service. Comments included, “Yes, I’m happy with her care overall and have confidence in them,” “Yes, the new manager is brilliant before it was chaotic when the old manager was there,” and “No, I don’t know the name of the manager, but that’s fine as not needed to speak with them as Mum is very happy being there and she is treated with respect. My questions are answered appropriately – in fact, they’ve exceeded my expectations.” However, many of the relatives we spoke with did not know who was managing the service, and there was a lack of clarity about staffs’ roles and responsibilities. Comments included, “They don’t wear name badges, so you don’t know who people are,” “I don’t know who the manager is. Is it [Team leader’s name], he seems quite competent. I don’t know people’s names or roles,” “I don’t know anyone. There was a lady called [Person’s name], but I think she left,” “I’m not sure who’s in charge. I had a good relationship with the old manager. I didn’t know she was leaving or that she’d gone.” And “There’s been lots of changes of managers – yoyo management. I don’t know who the manager is. Is it [Person’s name]? Or is it [Person’s name]? I’m not 100% sure.”

Throughout the assessment, the provider and senior management team were open with us, acknowledged any areas for improvement and were keen to put processes in place to address any areas of concern or improve practice. They talked about how they would use our feedback to develop their service improvement plan and improve the culture within the service. The manager told us when they had previously managed the service, they promoted continuous learning through meetings with staff to discuss work practices, training, and development needs. For example, staff supervision and team meetings were used to openly discuss staff practice and any additional training, which in turn better supported safe and effective practice. The provider told us they had met with the local authority’s commissioning team and had been honest and open with them about the challenges they faced. They assured us they had learnt from recent events, and whilst they could not change what had happened, they understood where things had gone wrong and were committed to getting it right moving forward.

At the time of the assessment, there was limited evidence to demonstrate quality assurance and compliance systems were instrumental in driving improvements, as they were either not undertaken robustly or had not taken place. Learning did not take place from accidents and incidents. For example, accident and incidents analysis did not reflect the levels of incidents taking place or identify if appropriate action had been taken. This meant this information could not be relied upon as a source to measure quality. Concerns and complaints from staff and relatives were not fully listened to or acted upon to help improve the quality of the care and support provided by the service. We reviewed a couple of recent complaints received from relatives. We noted the previous manager had not always understood the nature of the concerns raised, marginalised relatives’ concerns and failed to acknowledge where the service was not acting within the requirements of the regulation, or when they had simply got things wrong. We discussed what we had found with the provider, who told us whilst they had been aware of some of the concerns, they had not reviewed the response before it was sent out. Feedback was not sought from people, relatives, staff and other health and social care professionals or seen as an opportunity to support learning and development. The provider did have in place a service improvement plan at the time of the assessment. However, we found more work was needed to ensure this was fully reflective of the service and feedback we provided. Following the assessment, the provider confirmed they were working with the local authority to develop and review their existing service improvement plan