The Care Quality Commission (CQC) has downgraded the rating of Ashley Court Care Limited in Wolverhampton from requires improvement to inadequate and placed it into special measures to protect people following an inspection in November 2025.
Ashley Court Care Limited, run by a company of the same name, is a care home which provides support to older and younger people, some of whom are living with dementia.
CQC carried out the inspection following concerns it received about the care people were receiving.
Inspectors found that leaders hadn’t taken all the necessary actions needed to make improvements since CQC’s last inspection and the home was still in breach of two regulations in relation to safe care and treatment and management. During this inspection, CQC found four new breaches in relation to staffing, dignity and respect, person-centred care and the Mental Capacity Act (2005).
CQC has rated Ashley Court Care Limited as inadequate for being safe and well-led, down from requires improvement. The ratings for effective and caring and have dropped from good to inadequate, while responsive went from good to requires improvement.
CQC has placed the service into special measures which involves close monitoring to ensure people are safe while they make improvements. Special measures also provides a structured timeframe so services understand when they need to make improvements by, and what action CQC will take if this doesn’t happen.
CQC has also begun the process of taking regulatory action to address the concerns which Ashley Court Care Limited has the right to appeal.
Amanda Lyndon, CQC’s deputy director of adult social care for the West Midlands, said:
“When we inspected Ashley Court Care Limited, it was disappointing that despite outlining exactly where improvements were needed at our previous inspection, we found that leaders had allowed people’s care to deteriorate significantly and wasn’t always safe.
“During our inspection, we saw some people looking unclean and unkempt and had clearly not been supported to meet their personal needs. We asked staff for information about how people with mobility issues accessed the bath or shower but didn’t always receive it, indicating that people weren’t always receiving them.
“It was also concerning to see staff didn’t involve all people in decisions about their care or tell them about changes as a result. People’s care also didn’t always meet their diverse needs and preferences, and staff didn’t treat people respectfully or in a dignified way.
“Leaders didn’t have effective systems in place to help identify concerns or make improvements to people’s care. One person had been referred to an external health professional for sore skin. Despite this, we found this person seated in a wheelchair with no cushion or padding for a long time, putting them at risk of further sore skin.
“Although staff assessed information about incidents which took place, this wasn’t always used to earn lessons or make changes, putting people at potential risk of harm. Despite us asking for an action plan at our last inspection, it was clear that leaders hadn’t taken all the actions they said they were going to, keeping them in breach of the legal regulation relating to people’s safe care and treatment.
“We have again been clear with leaders about what we expect to see moving forward to ensure they are no longer in breach of regulations. We will return to check on their progress and have proposed using our regulatory powers further to ensure people are receiving the care they have a right to expect.”
Inspectors found:
- Staff didn’t have effective processes to follow to ensure people’s needs were assessed before they started using the service and care plans that were in place weren’t always updated accordingly, putting people at risk of receiving unsafe or unsuitable care.
- Leaders hadn’t assessed some areas of the home to ensure it met the needs of people who were living with dementia, such as some bedroom doors which were all the same colour which could cause confusion or loss of orientation.
- Staff didn’t interact with people unless it was task specific. Leaders didn’t always make sure there were enough staff, and during the day we witnessed periods when staff weren’t present in communal areas to support people.
- Staff didn’t ensure medicines were given to people or disposed of or stored safely, putting people at risk.
- Staff and leaders didn’t always fully consider the principles of the Mental Capacity Act (2005) putting people at risk of being unlawfully restricted and not giving appropriate consent to the care they received, such as relatives consenting to care without having the legal authority to do so.
- Leaders didn’t ensure the home was clean, and there was a strong smell throughout. During this inspection, CQC saw areas of the home that needed cleaning, such as toilets which posed a risk of infection.
- Leaders didn’t safely maintain all areas of the home, such as an exposed heater and warm piping, putting people and staff at risk of harm.