- Care home
Ash Hall Nursing Home
We served a warning notice on Ash Hall Limited on 20 December 2024 for failing to meet the regulations. The provider failed to ensure effective governance and oversight of the quality and safety of care people received.
Assessment report published 3 September 2026
Contents
Ratings
Our view of the service
Date of Assessment: 23 July to 11 August 2026. The service is a residential care home providing support to older people living with dementia, people with nursing needs, mental health conditions, physical disabilities and sensory impairments.
The provider was previously in breach of the legal regulations in relation to safe care and treatment and good governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations. We also identified additional concerns during this inspection, which meant the provider was in breach of the legal regulations relating to person-centred care, safe staffing and the need for consent.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
The provider could not demonstrate people consistently received safe care and treatment. Risks to people's health, safety and welfare were not always effectively assessed, monitored or managed. Concerns identified at the previous inspection, including staffing, environmental safety and oversight of care, had not been fully addressed. Systems for monitoring care delivery were ineffective, resulting in gaps in records, concerns with the management of time-critical medicines, and delays in people receiving support. Although audits and monitoring processes identified some issues, action taken had not resulted in sustained improvement. As a result, people remained at risk of harm.
People did not always receive effective care and support because systems for assessing needs, monitoring outcomes and reviewing care were inconsistently applied. Although staff understood people's health needs and people had access to healthcare services, gaps in oversight and record keeping meant there was limited assurance that care was consistently delivered in line with assessed needs and best practice.
Staff were described as kind, compassionate and respectful, and positive feedback was received from people and relatives about their approach. However, people did not always experience care which reflected their individual preferences and choices. Delays in receiving support also had the potential to impact people's dignity, comfort and wellbeing.
Care and support were not always organised around people's individual needs and preferences. Opportunities for people and relatives to influence service development were limited, information was not always available in accessible formats, and arrangements to promote social engagement and meaningful occupation were inconsistent. Systems were in place to support future care planning and access to healthcare services when required.
Leaders had not established effective governance and quality assurance systems to ensure safe, person-centred care or to continually drive sustained improvement. Concerns identified at the previous inspection and through enforcement activity had not been fully addressed, and oversight arrangements failed to identify and respond effectively to ongoing issues. As a result, the provider did not demonstrate a culture of continuous improvement, learning and accountability.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
People's experience of this service
People and their relatives were generally positive about the care provided. One person said, “I had a lovely welcome when I arrived.” People told us they felt safe living at the service and relatives said they were kept informed about important decisions. One relative told us, “They always ring me before making any decisions.” People also told us they received their medicines when needed and described the home as clean and comfortable.
People and relatives spoke positively about the support provided to maintain health and wellbeing. People told us staff supported them with medicines, nutrition and healthcare needs, and spoke positively about the quality of food. Relatives said healthcare professionals were involved when required and people generally felt able to make choices about their daily lives. However, some people experienced limited opportunities for social engagement.
People and relatives consistently described staff as kind, respectful and compassionate. One person told us, “The staff are all friendly, they are great.” We also used a tool called the Short Observational Framework for Inspection (SOFI). This helps inspectors understand the experiences of people who may not be able to tell us directly how they feel about the care they receive. Our observations found staff responded warmly to people and offered reassurance when needed. However, people often waited extended periods for assistance, and some felt staff were too busy to provide opportunities for conversation and personalised support.
People and relatives felt able to raise concerns and told us staff responded to healthcare needs when required. However, some people described delays in receiving support with daily routines and said opportunities for activities and meaningful occupation were limited, particularly when activity staff were unavailable. Feedback indicated care was not always delivered in a way which reflected people's individual preferences and interests.
While people expressed general satisfaction with their care and treatment, our assessment found elements of care which did not meet the expected standards.