Aston House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to need for consent and person centred care.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Care plans and risk assessments were not always sufficient, clear or consistent to enable them to meet people’s needs. We found care records were not up to date and did not reflect significant information from people’s past which could put people and others at risks, despite being regularly reviewed by management. This meant staff did not have accurate information to ensure the safe delivery of care.

On 19 and 27 February 2026 we noted there were insufficient staff numbers to evacuate people safely at night. According to the staffing rota, there was 1 sleep-in and 1 waking member of staff. However, we found at least 3 people required the assistance of 1 staff during evacuation. We reported this to the registered provider. On 10 March we reviewed updated PEEPs. According to new PEEPs everyone was evacuating independently. Whilst PEEPS had been updated, we were unsure how the registered provider had conducted their assessment. When we asked the Registered Provider whether people’s needs had changed or if any had become more independent during evacuations, we were told that needs had not changed, but their old PEEPs did not reflect their needs.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Care plans we reviewed were not person-centred, and specific details about people to help staff to care and support people appropriately. We also found content in the wrong sections of care plans, such as supporting people with the management of money and about self-harm in medication section. As many of the people living at the service, lived with risks to their health and wellbeing, there was a risk if information needed by staff was not in the correct place, it would not be accessed should an emergency occur.

One person’s care plan mentioned their mental health condition affected their nutrition. This was not explained in the ‘diabetes’, ‘psychological assessment’ or nutritional care plan. Staff told us, this referred to the person’s previous placement where the person was allegedly allowed to eat as many sugary foods as they wanted. However, the information about mental health affecting the person’s nutrition was explained only in the 'safe environment section'. This related to the person having periods of time without eating or drinking. 2 staff members we spoke to did not know this about the person’s support needs. We saw this person lost almost 4 kilograms in 3 weeks. There was no evidence of action taken to review if this weight loss was linked to the person’s mental health condition.

The registered provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

We saw there was limited information sharing which resulted in poor quality care plans. Staff were not always aware of details within care plans’ and did not always recognise risks related to people’s needs. The information shared between teams was not always checked and was not always accurate. There was no effort to assess people’s mental capacities and apply for Deprivation of Liberty Safeguards (DoLS) where appropriate. This meant there was a risk people may not receive the care they needed at the right time. The provider did not ensure staff worked collaboratively or shared essential information reliably, which limited the service’s ability to provide joined up‑, safe, and effective care.

The registered provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

We received mixed feedback from people regarding support received from staff to live healthier lives. One person told us, “I go for walks or walk into town. They encourage me to eat healthily. Everything is cooked from scratch.” However, another person told us, “I’m not encouraged to exercise.”

People received support from a range of external professionals to support them to manage their physical and mental health. However, we could not be assured staff always supported people to live healthily, due to gaps in their monitoring charts, the poor quality of care plans and lack of guidance for staff to follow.

The registered provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive andconsistent, or that they met both clinical expectations and the expectations of people themselves.

There was poor oversight of care records and assessments, and the electronic care planning system was not being used effectively to ensure people’s needs and planned outcomes were met.The registered provider was working on a service improvement plan. This was designed to improve care and outcomes for everyone. It detailed a lot of work the management and staff teams had done to better manage risk and improve the living environment for people. However, many of the concerns identified and addressed had been identified by Care Quality Commission, not by the provider’s quality assurance systems. Further work was needed to ensure the provider’s own monitoring systems could identify concerns effectively and enable improvements in care and safety for everyone.

People’s care was not consistently monitored or delivered in line with their risk assessments or the guidance provided by healthcare professionals. Staff did not always complete monitoring records to demonstrate people had received appropriate support.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

The service used a blanket approach that everyone has capacity, even where their care plans stated otherwise. Staff told us they did not carry out any mental capacity assessments, and they relied on the mental health team and the local authority to carry out those. Staff asked inspectors to show them a sample mental capacity assessment form during the second day of our inspection.

We found multiple restrictions on people, without evidence of their mental capacities being assessed, best interests or consent having been given by people with capacity.

The provider’s mental capacity act policy stated, ‘[acting manager] or a designated and trained individual will undertake mental capacity assessments when they are required’. The acting manager left the service following the first day of our inspection, and staff told us they are not trained to carry out mental capacity assessments. There was no specific training provided to staff on how to complete mental capacity assessment.

On 9 March 2026 the Registered Provider provided us with their action plan. However, we did not feel reassured as th shortfalls caused by the lack of mental capacity assessments and DoLS applications were not addressed. According to the action plan one person had a DoLS in place regarding their alcohol intake and signed the consent form regarding alcohol restrictions. The action plan failed to mention who would be sufficiently qualified or knowledgeable to carry out the mental capacity assessments.

On 10 March 2026 we found multiple residents who lacked capacity to consent, signed forms for areas in which they did not have the capacity to provide informed consent. For example, a person who was assessed by a psychiatrist to lack capacity with regards to their health and wellbeing, housing and financing signed consent form to have their medicines administered by staff.