Ashleigh Manor Residential Care Home remains in special measures following CQC inspection

The Care Quality Commission (CQC) has again rated Ashleigh Manor Residential Care Home in Plymouth as Inadequate following an inspection that concluded in May, with the regulator taking further enforcement action after finding significant concerns remained.

Ashleigh Manor Residential Care Home provides care for older people, including people living with dementia and frailty. At the time of the inspection, 55 people were living at the home.

The inspection was carried out to review progress after a previous visit identified nine breaches of regulations. While inspectors found two issues had been resolved, including failures to submit required notifications and display the correct CQC rating, the service remained in breach of seven regulations.

These related to safe care and treatment, person-centred care, consent, safeguarding, dignity and respect, staffing levels and the overall management of the service.

As a result of the inspection, CQC has again rated the home as Inadequate for Safe, Effective and Well-led. The Caring and Responsive ratings have also been downgraded from Good to Requires Improvement.

The regulator has imposed additional conditions on the home’s registration. Before admitting any new residents, the provider must complete a thorough assessment of each person’s needs and provide CQC with monthly updates on the progress being made to improve the service.

Ashleigh Manor remains in special measures, meaning the service will continue to be closely monitored while improvements are made. The special measures process also sets clear expectations for when improvements must be achieved and what further action may be taken if standards do not improve.

During the inspection, CQC found that although some improvements had been introduced since the previous visit, they had not addressed the underlying concerns. Inspectors reported that care plans and risk assessments often contained generic or conflicting information and did not always reflect people’s current needs, creating a risk that staff may not provide appropriate care.

Inspectors also identified concerns around medicines management. Medicines cabinets were not always secured, and there were occasions where records showed medicines had been administered even though they remained in their original packaging, raising concerns that people may not have received the medication they required.

Although people and their relatives generally described positive day-to-day experiences, inspectors found examples where people’s privacy and dignity were not consistently respected, including bedroom doors being left open while residents were in bed.

The inspection also found inconsistent understanding of legal safeguards designed to protect people’s rights. Inspectors reported instances where restrictions were placed on people without clear evidence they were necessary or in the person’s best interests, including the use of medicines to manage behaviour and supervision of visits.

Additional concerns identified by CQC included incomplete safeguarding training for staff, unresolved fire safety issues, limited involvement of people and relatives in care planning, staffing levels that did not always meet people’s needs, particularly overnight, and quality assurance systems that failed to identify inaccurate or incomplete risk assessments despite routine checks being recorded.

The CQC said it will continue to monitor the service closely while the provider works to make the required improvements.

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