Date of assessment 25 July to 2nd September 2025. Ashton Care Limited is a domiciliary service providing personal care support to 10 people in their own homes. During our visit we identified through discussions with the provider that the regulated activity personal care was also being delivered by the provider at a supported living service, which we visited on 19 August 2025. We have undertaken a comprehensive inspection which means we have reviewed all 33 quality statements. As a result of this inspection, we have rated the service as good for safe, effective, caring, responsive and well-led, leading to a good overall rating for the service. We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and access to communities that most people take for granted. ‘Right support, right care, right culture’ is a guidance CQC follows to make assessments and judgements about services supporting people which providers must adhere to. People’s care plans were well written with a level of detail that made it easy for staff to follow. Plans were person centred, outlining skills people already had and areas of support they required to maximise their independence. People who used the service and their families told us that they were happy with the support they received. Many who we spoke to told us about the consistency in having the same staff which helped. They told us about how staff are friendly and supportive and how they supported their loved ones to engage in different activities. The staff we met were well established and understood people’s needs. They told us that they received the training they needed to do their jobs and could approach the Registered manager for support whenever they needed to. Staff also told us how they felt confident in being able to talk to their managers if they needed to share any concerns. A professional we spoke to told us that they felt the provider kept people safe and added how the provider is committed to the wellbeing of people it supported. The provider had robust systems in place to meet the needs of the people in both the community setting and within its supported living service. However, were needed in the way medicines administration was recorded. We carried out our last assessment of this service on 15 March 2023. Our overall rating was ‘requires improvement’. At this assessment we have rated the service overall ‘good’.
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Ashton Care Ltd was rated Requires Improvement overall following a March–April 2023 inspection, with a breach of Regulation 17 identified due to incomplete records, ineffective governance systems, and a serious incident not reported to CQC. Key concerns centred on unverifiable staff training, incomplete risk assessments, and poor incident-learning processes, despite people and relatives reporting kind, culturally aware and dignified care.
Concerns (8)
criticalGovernance: “people were put at risk of harm because systems were not robust and records about care were not complete and contemporaneous. This was a breach of regulation 17.”
criticalIncident learning: “we were alerted to serious incident which had not yet been reported to CQC...we were not able to fully assess how learning from incidents had occurred.”
criticalSafeguarding: “The registered manager was not aware this was a reportable incident...This was submitted in retrospect.”
moderateCare planning: “questions related to the assistance a person required and frequency, these were left blank. Also, risks related to the use of a bath board were not documented.”
moderateStaff training: “I have worked for Ashton Care since [month] and I haven't received any training at all. Neither have [other staff].”
moderateSupervision / appraisal: “Staff records showed staff had completed training...This conflicted with staff feedback, none of the staff we spoke with had received training or a formal supervision.”
moderateRecord keeping: “Recruitment records were not always accurate and up to date...Daily logs required more details about people's choices. Some logs did not detail duration of visits.”
minorConsent / capacity: “consent forms contained some details, but were not signed by people using the service or where appropriate their legal representative.”
Strengths
· People and relatives felt the service was safe and staff were kind, caring and compassionate.
· Staff promoted equality and diversity, understood people's cultural needs and provided culturally appropriate care.
· Staff communicated with people in ways that met their needs and promoted independence.
· Recruitment was mostly safe with right-to-work and DBS checks in place.
· Staff wore appropriate PPE and infection control measures were observed.
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standardsGood
Ashton Care Ltd was rated Requires Improvement overall following its first inspection in April 2018, with two regulatory breaches found: failure to follow correct child protection reporting procedures (Regulation 13) and inadequate staff recruitment checks (Regulation 19). The service demonstrated strengths in person-centred care planning, caring staff, responsive practice and adequate staffing, with Effective, Caring and Responsive domains all rated Good.
Concerns (4)
criticalSafeguarding: “the provider had not followed the correct reporting process in line with child protection procedures as these were not understood by the registered manager”
criticalGovernance: “the provider had not operated effective systems to ensure safe recruitment and had failed to ensure that all staff understood child protection reporting procedures”
criticalStaff competency: “employment dates were missing on all of the employment and character references we checked to ensure staff had provided accurate information”
minorRecord keeping: “the provider's statement of purpose was not updated to reflect this”
Strengths
· Care plans were tailored to meet people's individual needs with a good emphasis on personalised care and regular reviews
· Parents spoke positively about caring staff who knew their family members well and respected their privacy and dignity
· Adequate staffing levels with care calls delivered on time and staff informing families of any delays
· People's cultural, spiritual and communication needs were taken into account during the care planning process
· Regular audits, spot checks and feedback mechanisms were in place to oversee and improve service delivery
Quality-Statement breakdown (13)
safe: SafeguardingRequires improvement
safe: Fit and proper persons employedRequires improvement
safe: Risk assessment and managementGood
safe: Staffing levelsGood
effective: Staff training and supportGood
effective: Consent and capacityGood
effective: Nutrition and hydrationGood
caring: Treating people with dignity and respectGood
36-40 Copperfield Road improved from Requires Improvement to Good across all five key questions, having addressed prior breaches in safeguarding and safer recruitment. Minor gaps remain around Mental Capacity Act preparatory work for children approaching adulthood and formalising incident-learning processes.
Concerns (3)
minorConsent / capacity: “Where children were approaching adulthood, the provider was yet to carry out preparatory work to ensure that their future care was delivered in line with the MCA.”
minorIncident learning: “The provider's process was clear about identifying reasons for incidents but was not written in a way which ensured lesson were learned when things had gone wrong.”
minorStaff competency: “Some parents told us that sometimes care workers did not speak good English. The provider had arranged for staff to undertake English courses when this was identified as a development need.”
Strengths
· Safeguarding processes significantly improved since last inspection, with provider working with local authority to raise awareness of child abuse and female genital mutilation.
· Safer recruitment processes now fully met regulation, including DBS checks, references, and right-to-work verification.
· Children consistently supported by the same care worker, with care workers able to converse in the child's first language.
· Detailed care assessments and personalised care plans addressing cultural, religious, dietary, and communication needs.
· Registered manager conducted monthly spot checks, quarterly supervision, and yearly appraisals to support staff development.
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives and access healthcare servicesGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisionsGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; working in partnership with othersGood
caring: Person-centred relationships
Good
responsive: Care planning and assessmentGood
responsive: Complaints handlingGood
well-led: Governance and oversightRequires improvement