During an assessment under our new approach
Date of Assessment 25 June to 30 July 2025. This assessment included site visits to the service on 1, 2 and 8 July 2025.
Astley Hall is a care home with nursing providing accommodation and personal care to older people, including people living with dementia and physical frailty. The service is registered to support up to 83 people.
This assessment was prompted in part by concerns received about the leadership, people’s safe care and whether staffing levels and staff skill met the needs of people using the service safely.
At this assessment, there were 71 people using the service. We spoke with 19 people who used the service and 16 relatives. We spoke with 24 staff including the manager, the clinical lead, care staff, the catering staff, the activity staff, domestic staff, and the regional manager representing the provider. We also spoke with visiting professionals. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We looked at 11 people’s care records and multiple monitoring records including medicine records. We looked at 5 staff files and multiple management records including policies and procedures.
We found that whilst the service demonstrated some good practice, improvements were needed to ensure consistent delivery of high-quality care across all areas. We identified three breaches of regulation regarding safe care and treatment, staffing and governance. We have asked the provider for an action plan in relation to the concerns found.
The provider’s learning culture needed to improve. Whilst accidents and incident were analysed to identify themes so action could be taken to prevent recurrence, daily management oversight was not effective as risks were not always recognised.
Management oversight, governance systems and audits had not been used effectively to assess, monitor and improve the quality and safety of the service. Concerns were identified in relation to people’s assessed needs, health risks and inaccurate care plans and gaps in the monitoring records showed these were not fully effective. The provider’s management team were transparent and responsive to the concerns and shortfalls we identified. Their commitment was evident by some immediate action taken to reduce risks but further improvements were needed.
Staff were recruited safely. The oversight of staffing levels and staff deployment needed to improve. We were not assured staffing levels met people’s individual needs and this also compromised people’s dignity, independence and respect at time. Systems were in place to support staff, but most staff were not confident to speak up. Staff training was up to date and they understood their responsibility to protect people from abuse.
Staff treated people with kindness, compassion and supported their preferences. Staff were committed providing people they looked after and had development positive relationships with people and their relatives. People lived in a clean and well-maintained home. People had personalised their rooms to reflect their taste and interests. People maintained relationships with family and friends. The provider had plans in place to manage unplanned events and emergencies. Information was available in formats people could understand.