Ash Hall Nursing Home

On this page

• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment and staffing.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not promote a proactive and positive culture of safety. Concerns identified at our previous inspection remained evident at this inspection, despite enforcement action. This demonstrated that lessons were not consistently learned, embedded, or used to improve outcomes for people.

At the previous inspection, we issued a Warning Notice in relation to concerns regarding the governance of care delivery, staffing and the environment. During this inspection, we found some of these concerns had not been fully addressed and similar issues continued to occur. This demonstrated the provider had not taken effective action to embed and sustain improvements or to ensure all requirements of the Warning Notice were met. For example, concerns identified through audits continued to reoccur, environmental risks remained inadequately managed, and people experienced delays in receiving support with their care needs. This indicated lessons had not been effectively learned from previous incidents, feedback and enforcement action.

Despite this, people told us they felt safe living at the service. One person told us, “I feel safe living here.” Staff told us accidents and incidents were reviewed, and learning was shared through debrief sessions. One staff member said, “I feel all incidents are taken seriously and investigated by [the registered manager]. The registered manager then determines which actions, if any, need to be taken and will update me on what the outcome has been.”

Whilst the provider completed assessments and made appropriate referrals to external health and social care professionals when required, systems for monitoring and managing people's needs were not always safe or effective.

We identified concerns regarding the management of risks for 1 person who had recently been admitted to the service. During our inspection, the person's bed rails were in use without bed rail bumpers in place. When requested, staff were unable to provide a bed rail risk assessment. Following our feedback, the registered manager immediately reviewed the person's needs and ensured appropriate bed rail bumpers were fitted. However, the lack of an assessment meant the provider could not demonstrate risks associated with the use of bed rails had been appropriately considered and managed.

Systems intended to identify and monitor people's health needs were not consistently effective. We found repeated omissions in care records, including documentation relating to the application of prescribed topical medicines and the provision of oral care. Accurate records are important in demonstrating care has been delivered and in identifying changes in people's health and wellbeing. The gaps identified meant there was a risk signs of deteriorating health or unmet needs may not be recognised promptly, potentially delaying referrals to relevant healthcare professionals.

People told us staff responded appropriately when they required medical support and helped them access healthcare services when needed. One person told us, "If you need to see a doctor they [staff] will get an appointment for you."

People told us they were made to feel welcome when they moved into the service, and staff demonstrated a good understanding of people's individual care needs.

A healthcare professional told us the provider followed their recommendations and worked appropriately with external professionals involved in people's care.

People were not always protected by effective systems to identify and respond to potential safeguarding risks, although staff understood safeguarding procedures and concerns were reported appropriately. Gaps in the monitoring of people’s care and record keeping meant the provider could not always demonstrate people consistently received their planned care. This meant there was limited assurance that missed or unmet care needs would be identified and responded to promptly and reduced opportunities to recognise potential indicators of neglect at the earliest stage.

We reviewed how the service applied the Mental Capacity Act 2005 (MCA), including the management of Deprivation of Liberty Safeguards (DoLS). People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005(MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found arrangements for obtaining consent and making decisions in people's best interests were not always clearly documented or in place where restrictions had been implemented. For example, where people were subject to restrictions such as bed rails, specialist chairs or being nursed in bed, best interest decision-making had not always been completed. This meant the provider could not demonstrate restrictions were necessary, proportionate and applied in people's best interests, placing people at risk of having their rights unnecessarily restricted.

Relatives told us people received safe care and support. One relative said, “Everything is as well as it can be with [person's] care.”

Staff demonstrated a good understanding of safeguarding and were clear about their responsibilities to report concerns. One staff member told us, “I've done safeguarding training. I would report any concerns straight away to the registered manager.”

The provider did not always work effectively with people and those important to them to understand and manage risks.

Where people were cared for in bed, there were not always clear records demonstrating how decisions had been made in their best interests or how people and those important to them had been involved in discussions about restrictions to their care. The provider told us these discussions took place but acknowledged they were not always documented.

For example, 1 person told us they were unsure why they did not have access to a call bell. We reviewed their care plan, which stated a call bell should be available at their bedside. The registered manager told us the call bell had been removed following a previous incident; however, there was no documented assessment, best interest decision or care plan update to support this action. On the second day of the inspection, the call bell was returned and the provider told us they would improve the recording of such decisions in future.

The absence of clear records meant the provider could not demonstrate that people, or those acting on their behalf, had been appropriately involved in decisions about their care and risk management. However, staff described how they supported people to understand risks and make informed decisions about their care and support. One staff member said, “I support people’s decisions by helping to keep them informed with what is going on or if something has changed in their circumstances.”

The provider did not always identify, assess and mitigate risks within the care environment and could not demonstrate equipment, facilities and premises consistently supported the delivery of safe care.

At the previous inspection, we identified concerns relating to the absence of suitable window restrictors. During this inspection, 2 first-floor windows and 1 ground-floor window continued to lack appropriate restrictors, demonstrating the provider had not taken sufficient action to address a known hazard.

We also found radiators and pipework uncovered which presented a risk of burns. Although the provider completed monthly temperature checks, these were limited to sample readings and did not include all hot water outlets and surfaces. Environmental risk assessments did not adequately consider foreseeable risks, particularly in relation to future admissions of people with greater mobility and independence.

We also raised concerns regarding fire safety and the provider's response to maintenance issues. We reviewed an audit completed 4 months before the inspection which identified 4 fire doors were not closing properly. The issue had been recorded in the maintenance log. During the inspection, we tested the same fire doors and found they continued not to close fully. Maintenance records showed the concern had been recorded again on 17 June 2026. Despite the issue being identified on more than 1 occasion, there was no evidence timely remedial action had been taken. This placed people at risk of harm in the event of a fire due to the lack of action taken by the provider to ensure the fire doors were functioning and fit for purpose.

We also identified 2 people using bed rails without the required protective bumpers, increasing the risk of injury.

Following feedback during the inspection, the provider took action, including installing window restrictors, repairing the fire doors, replacing protective bumpers and updating risk assessments to include monthly checks of water outlet and surface temperatures. They also advised they would review maintenance monitoring arrangements as part of their governance processes. However, these actions were reactive and did not provide assurance environmental hazards had been identified and addressed before our inspection.

These findings demonstrated the provider had not consistently identified, assessed and managed environmental and fire safety hazards. Known concerns had not always been addressed in a timely manner, placing people at risk of avoidable harm and reducing assurance the environment was safely maintained.

The provider did not ensure there were enough suitably qualified, skilled and experienced staff deployed effectively to meet people's needs.

At the previous inspection, we identified concerns about delays in people receiving support after requesting assistance. During this inspection, similar concerns remained. The provider's own call bell audit, completed in March 2026, identified prolonged response times, including occasions where call bells were not answered for over an hour. Although these findings had been discussed during staff meetings, the provider had not completed any further audit to assess whether improvements had been achieved. Our observations during the inspection highlighted people continued to experience delays in receiving support with their care needs.

The provider did not consistently monitor staff training. One staff member working during the inspection was not included on the mandatory training matrix, meaning the provider could not demonstrate they had completed required training. We also found mandatory training had not been completed by all staff and some courses had not been allocated to staff members. In addition, staff had not completed training relating to learning disability or autism. We requested evidence to demonstrate training compliance across the workforce through a training audit, the provider was unable to provide this.

These findings demonstrated the provider could not demonstrate staffing arrangements were consistently effective in meeting people's needs. Known delays in responding to requests for support persisted, and gaps in training oversight meant the provider could not be assured staff had the knowledge and skills required to deliver safe care.

However, staff told us they felt confident and competent in their roles, and we observed positive moving and handling practices. Staff were recruited safely.

People told us staff were kind, although they often appeared busy and had limited time to spend with them. One person said, "I think they need more staff. I only really see them at mealtimes. They have no time for a chat. I don't see the same staff, so it is difficult to get to know any of them." Another person told us, "They could do with more staff. They seem busy all the time. I don't use the call bell because they are too busy."

The provider did not always effectively assess and manage the risk of infection.

The home was clean and free from malodour. However, some areas of the environment appeared worn and in need of refurbishment, which could impact on the provider's ability to maintain effective infection prevention and control standards over time. We observed maintenance works being undertaken during the inspection.

We also identified concerns regarding cleaning products being left unattended in communal areas by domestic staff. This created a risk to people's safety and demonstrated a lack of oversight of safe working practices. Following our feedback, the provider acted promptly to secure cleaning products in locked storage boxes.

People and relatives told us the home was clean and well maintained. One person told us, “The home is spotless. They [staff] come round every night to clean.”

Staff told us the home was regularly cleaned but needed refurbishment. One staff member said, “The home is mostly clean. Some bedrooms look run down, but that is more because they need redecorating rather than being dirty.”

The provider did not always ensure medicines were managed and administered safely.

Where people were prescribed topical creams, records showed these were not always applied as prescribed. Staff did not consistently record the administration times of time-sensitive medicines, meaning the provider could not be assured people received these medicines at the correct intervals. We also found medicines administered via transdermal patches were not always rotated in accordance with manufacturer guidance, increasing the risk of reduced effectiveness or skin irritation.

These concerns meant the provider could not be assured medicines were always administered safely and as prescribed. Following our feedback, the provider contacted the pharmacy to amend documentation so administration times were clearly recorded and improved the monitoring records used for transdermal patch rotation.

Despite these concerns, appropriate protocols were in place where people received medicines on an 'as required' basis or where medicines were administered covertly. Medicines were stored securely, stock balances matched administration records and people told us they received their medicines when needed. We observed staff administering medicines in a dignified and respectful manner.