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Ashleigh House Requires improvement

The provider of this service changed - see old profile

We are carrying out a review of quality at Ashleigh House. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 18 May 2018

This inspection of Ashleigh House took place on 28 March, 6 and 24 April 2018. It was an unannounced inspection which meant that the staff and provider did not know that we would be visiting. During this period we also received information from the registered manager, such as an action plan and discussed the expected changes to the service with them and the area manager.

We last inspected this service in 28 September 2015, and found the service was complying with all the regulations and we rated the service as ‘Good.’

In November 2017 owners of Salutem Healthcare replaced the directors of Pathways Care Group Limited and took over the operation of the service. This change of leadership also meant that the provider has become a part of a wider Salutem Healthcare consortium. Pathways Care Group Limited remains listed, as an active legal entity on Company House and thus remains appropriately registered with CQC. However, some of their documentation contains information about this new company, as does the website.

During this inspection we found the service needed to take action to ensure they met all the fundamental standards we inspected against.

Ashleigh House is a ‘care home’. People in care homes receive accommodation and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Ashleigh House is registered to provide care and accommodation for up to 30 people who are living with dementia or a mental health condition. On the day of our inspection there were 15 people using the service.

Whilst reviewing the information for the service we found that since the last inspection the provider’s website had changed and stated that Ashleigh House provided 20 places for people living with dementia and people with a mental health condition in to two 10 place units. However, we found this was not the case as 27 places were available for people with mental health needs. The provider rectified the website immediately.

The registered manager told us that the service was being redesigned and would offer services for people living with mental health conditions who needed 24 hour support and then progressive step-down and transition services, which were aimed at supporting people to move to their own accommodation. The regional manager also discussed future plans for the service such as employing a clinical nurse lead and opening a day unit that provided drop-in services, a meal on a Sunday, access to welfare and citizens advice for local people living with mental health needs. The intention they told us was to offer wider services so that outreach and supported living provision could also be offered from Ashleigh House.

We discussed with the regional manager and registered manager the need to submit an application to vary their conditions of registration so the number of available places could be reduced to 27. As some of the people at the service were also living with a learning disability that this needed to be added their service user bands. They undertook to do this immediately.

The service had a manager who became the registered manager in September 2015. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

On the first day of the inspection we found that the lift had been out of order for a year. Also the local NHS Trust’s infection control team had visited the previous year and required a number of changes to the environment to be made immediately, which included replacing flooring. We found that although some of the damaged flooring had been replaced other areas such as stairs needed immediate attention. The outside of the building was t

Inspection areas


Requires improvement

Updated 18 May 2018

The service was not always safe.

Risk assessments needed to be improved.

The service was not clean or well maintained.

Medicines were safely and appropriately managed.

Staff could recognise signs of potential abuse and reported any concerns.

Appropriate recruitment procedures had been completed.


Requires improvement

Updated 18 May 2018

The service was not always effective.

Assessments did not contain sufficient information to ensure staff understood people's needs, their history and potential triggers for offending behaviour or the measures that could be used to reduce any risks.

People’s consent was not always sought. The documentation linked to the application of the Mental Capacity Act 2005 was not in place.

Staff needed to gain the knowledge and skills to fully support people who used the service.

People were provided with a choice of nutritious food and their on-going healthcare needs were managed.

The environment met people's needs.



Updated 18 May 2018

The service was caring.

People were treated with respect and their independence, privacy and dignity were promoted.

Staff knew people well and involved them in conversations about their care.

Staff interacted with people in a way which was kind, compassionate and caring.


Requires improvement

Updated 18 May 2018

The service was not always responsive.

Although the registered manager updated care records following our first visits previously these had not been reviewed for several years and were out of date.

People could take part in activities but most were very independent and organised their own day.

The people we spoke with were aware of how to make a complaint or raise a concern, however at times staff needed to ensure these and the action taken was recorded in the complaint's log.


Requires improvement

Updated 18 May 2018

The service was not always well-led.

The systems for assessing and monitoring the performance of the service were not always effective.

The provider had been making changes at the service but these were at an early stage and therefore it was unknown if these would be sustained.

People and relatives’ views had been sought.