Ash Grange Nursing Home

The following is CQC's published account of its assessment, published 3 September 2026. References to “we” mean CQC. It describes findings at that time.

About the service

The service is a nursing home which has 2 floors, each providing care and support to people with nursing needs. There were 35 people using the service at the time of the inspection.

Who the service is for

This service provides support to younger and older people with nursing needs, physical disabilities and dementia.

Key findingsWe carried out this assessment on 11 August 2026. This service was previously rated as good at our last inspection which was published on 19 March 2021. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.

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 that staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions they had choice, control and freedom over their lives.

The provider’s systems ensured where people required a DoLS these were in place and individual care plans reflected the content. Not everyone was subject to a DoLS. The system ensured assessments were completed and applications were made. There was a process to track these to ensure any new applications were made in a timely way. Staff could describe who had a DoLS in place and what this meant for each person.

Systems are in place to review all incidents and learn lessons when things went wrong. The registered manager told us, “Learning from incidents report are completed following an event and we share the lessons learned with staff.” Staff confirmed they received information in meetings and supervisions about lessons learned. We saw incident analysis considered a range of factors to determine if there were any lessons to be learned. Where lessons had been identified relevant updates were made and staff were informed. For example, following a complaint being considered the registered manager had made changes to hospital admissions processes.

Staff understood how to recognise abuse and could describe the actions they would take to report any concerns. Staff had received training to support their practice and there was a whistleblowing policy in place. Where incidents had happened, the registered manager had reported these to the appropriate body, and we saw all incidents were monitored to track the outcomes and internal reviews were undertaken to identify any wider themes or learning.

There was a system in place to assess risks to people’s safety. Where risks were identified these were assessed and management plans were put in place. We saw people had different risk assessments depending on their assessed needs, these included risks relating to mobility, falls, skin integrity, eating, drinking and for specific health conditions such as diabetes and Parkinson’s disease. Staff could describe the support people needed to minimise the risks to their safety and our observations confirmed staff followed peoples plans. Risks relating to the environment were also considered and systems were in place to ensure the home and equipment were well maintained.

People received their medicines as prescribed. Medicines administration records were also in place and accurately completed. Guidance was in place for where people needed as required medicines and medicines were stored safely. Nurses were observed seeking consent from people to accept their medicines and administering these safely.

People had an initial assessment which identified their needs and outcomes. Staff told us they received information about people’s needs through the electronic assessment and care plan. We saw the system identified people’s individual needs and preferences and documented the outcomes they wanted to achieve. The system then produced a care plan to guide staff on how to meet these for each person. The electronic record also ensured people had regular reviews of their needs and outcomes, and evidence-based tools were included in the system. Staff told us they had a good summary included of people’s needs and the record was also used to document the care people received. A staff member said, “These are good and updated regularly we all know what is in place for people, it flags and tells you what needs to be done when. It is easy to record on the system when we deliver peoples care.” Where people could not consent to their care, we saw mental capacity assessments were completed and decisions were taken in people’s best interests.

Staff knew people well and could describe how they supported people to meet their needs. Staff were observed supporting people to remain independent. For example, people were given adapted cups to be able to drink themselves. Staff were consistently offering people choices throughout the day. People were given a choice of where to sit, what activities they wanted to do and what meals they would like. The registered manager told us they had various systems in place to check on how well staff engaged with people during their care. They described spot checks where observations were completed, regular feedback from people and their relatives and the nursing team having continuous oversight of staff practice. The registered manager also told us, “We have a culture of staff being able to share any concerns anonymously with me so these can be addressed in supervision with staff.”

People’s individual needs and preferences were understood by staff. Staff could describe in detail the information they needed to provide peoples care in the way they needed and preferred. For example, staff could tell us about preferences for how personal care should be delivered, preferences around frequency and which toiletries people liked to have and how they got these. Staff could tell when people needed support, they were observed being responsive when people needed help. A staff member told us, “Bedtimes are agreed with people and what time they get up. Some people decline on the day, and this is always respected. Personal care is done as the care plan tells us to and this gives us all the detail we need. All areas of protected characteristics are covered in peoples care plans for example, it will say about cultural needs or religion.”

Staff understood how to support people to raise concerns and told us they would have no hesitation in doing so. A staff member told us, “If someone made a complaint or anything else I would report this to the nurse in charge for action or the manager.” We saw there was a complaint log in place which detailed any concerns raised, the investigation undertaken and the outcome. The registered manager told us learning from complaints was in place and provided an example of how they looked for themes and trends when receiving concerns.

Systems to check people received their care were operating effectively and audits were in place to check medicines administration was done safely. The registered manager had systems in place which supported learning and there was a clear understanding of the providers vision for the service.

Some improvements were needed to safe staffing levels were maintained. For example, we observed staff were not consistently available in communal areas which meant people sometimes had to wait for their support. The registered manager explained the service had experienced staffing shortages on the day of the inspection and this had impacted peoples experience on the day. The registered manager confirmed action had been taken to prevent this from happening again.

Systems to ensure there were sufficient staff available to support people were not consistently effective. We found despite systems being in place to check and determine staffing levels based on individual dependency on the day of the inspection these had not been effective and there were not enough staff to meet people’s needs in a timely way.