Ashleigh Manor Residential Care Home

The purpose of this assessment was to check whether the Warning Notices served in relation to breaches of regulation for safe care and treatment, safeguarding and governance following our previous assessment in September 2025,had been met. Our assessmentidentified7breaches of legal requirements in relation to safeguarding, safe care and treatment, need for consent, person-centred care, dignity, staffing, and good governance.

People were not always protected from the risk of harm because staff did not consistently have all the information needed to meet people’s needs safely. Following the previous assessment, the provider and registered manager had taken some action to improve the service. There were improvements in areas such as aspects of medicines management, the recording of topical medicines, and the environment, including reduced odour and some improvements to infection prevention and control. Governance systems had been strengthened and there was evidence of increased leadership presence and engagement with staff. Staff and external professionals also provided some positive feedback about the caring approach of staff and communication within the service.

However, these improvements were not consistently embedded and did not ensure people always received safe, person-centred care. Evidence from care records, staff feedback and direct observation showed ongoing and widespread concerns. Care plans and risk assessments were often generic, inconsistent or contained conflicting information, and did not always reflect people’s current needs. This meant staff did not always have clear guidance to provide safe care.

People were not always protected from avoidable harm. The management of risks relating to falls, skin integrity, nutrition, epilepsy and environmental safety was inconsistent. In some cases, identified risks had not been assessed or mitigated, and staff did not always follow care plans. Medicines were not always managed safely, with gaps in administration records, issues with storage and a lack of clear protocols for some high-risk medicines.

People’s rights were not always upheld. The provider did not always follow the principles of the Mental Capacity Act 2005. We found inconsistencies in capacity assessments, best interest decision-making and the use of restrictive practices. Some restrictions on people’s care and movement were in place without appropriate legal frameworks or clear documentation.

Staffing systems did not always ensure staff had the skills, training and support they needed. Training records showed gaps in mandatory training, supervision and competency checks were not consistently effective. Staff told us they often relied on verbal handovers rather than care records, which increased the risk of inconsistent care delivery.

Governance systems remained ineffective in identifying and addressing risks. Although audits and oversight processes had been introduced or strengthened, they had not identified the concerns we found during this assessment. This meant leaders did not always have an accurate understanding of the quality and safety of the service.

At this assessment, the overall rating remains inadequate. This service remains 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.

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. In addition, we have asked the provider for an action plan in response to the concerns found at this assessment.