Ailwyn Hall

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 consent.

This service scored 29 (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 were effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People had their needs assessed before being admitted to the service but information about people’s needs was not always clearly recorded. Two care plans had other people’s names recorded and we found some people’s care did not correspond to their assessed needs. For example, one person wore a full head protector at night but the assessed need for this was not documented in any care and support plans. Staff gave us differing views on why it was in place and told us the person did not like it and found it uncomfortable.

Permanent staff we spoke with knew people well and were aware of people’s histories and care needs, but the high numbers of agency staff did not have access to the electronic recording system and so were not able to identify people’s needs or update records easily. We raised this as an issue on our first onsite visit on 02 February 2026 and the provider had made improvements by the time of our final visit on 18 March 2026. Agency staff were observed providing one-to-one care for people without any induction or understanding of people’s assessed 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.

The service used industry recognized tools such as the Waterlow Scale for pressure ulcer risk and MUST (Malnutrition Universal Screening Tool) for weight management. However, these were not always accurately calculated which could lead to risks not being effectively managed. Where risks had been calculated the correct actions were not always in place. For example, 3 people’s MUST scores had been incorrectly calculated which placed them at risk of not receiving the care, monitoring and ongoing treatment they required.

Where people had been assessed as being at high risk of developing a pressure ulcer, a repositioning regime was put in place. However, records showed people were not always being repositioned in line with this which placed them at an increased risk of developing a pressure ulcer. One person’s records showed there were multiple times when they were not repositioned within the required 2 hour timeframe and also when they were repositioned back onto the same side which increased the risk of skin breakdown in that area.

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

Processes to hand information over from shift to shift were not effective and staff were not always aware of the most current changes in a person’s needs and care requirements. We observed a staff handover during an out-of-hours onsite visit and staff were unclear about some key details relating to the people who used the service, including whether the body of a person who had passed away was still in the building. Staff were also not able to confirm how the referral for one person’s mental health assessment was progressing and a lack of handheld electronic devices to view care plans and make notes made it more of a challenge for staff. During our assessment process, the service purchased additional devices to improve this.

Following our first onsite visit, a new handover system was introduced. However, this was not always used as intended and, although it had been put in place on 05 February, the new routines were still not fully embedded by the end of the assessment process on 18 March.

Sharing of information with agency staff was very poor and left people who used the service at risk of receiving poor care which did not meet their needs. By the time of our final onsite visit, a new system had been put in place which aimed to ensure key information, especially for those agency staff providing one-to-one care, was clearer, however this had not been embedded.

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

We received mixed feedback from relatives of people who used the service regarding how their family member’s health needs were managed. One person told us, ‘[My relative] should be wearing glasses and we asked [the manager] for an optician’s appointment but they just said [my relative] was uncompliant.’ However, another commented, ‘As far as I know [my relative] gets to see the doctor when necessary. [They] got conjunctivitis and [the staff] were on it very quickly.’

Health needs were assessed and documented in care plans, however these were not promptly updated when people’s needs changed. For example, where people had lost weight or had a recent fall, care plans which we viewed did not promptly reflect this new information. Care plans documented people’s eating and drinking but relatives voiced concerns about people getting enough to drink. One told us, ‘I do question whether they do everything to keep [my relative] hydrated. Monday to Friday is fine but sometimes when I visit at the weekend [they are] really thirsty.’

Some people experienced high numbers of falls and action to mitigate this risk was not in place. One person had a certain type of alarm to alert staff they had left a chair which had been suggested by an occupational therapist, but this had not been provided. A relative told us their family member experienced 34 falls in 6 months and was always told this was due to the progression of their dementia.

People’s risk of choking was not always accurately documented in care plans. Equipment was in place to assist with a choking emergency, however staff had not all had the required training to use this equipment safely. The provider removed these devices whilst we were onsite.

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

Whilst some staff demonstrated a good understanding of people’s needs, agency staff and the service’s own systems did not support effective monitoring and oversight. Care records were not always accurate and oversight was poor in some areas which impacted people’s care.

A resident of the day initiative was in place. This is designed to have a more structured overview of people’s care on a rolling programme. Relatives gave us mixed feedback about this.

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

We identified assessments of people’s mental capacity to consent to care and treatment had not been carried out in line with the Mental Capacity Act 2005. We noted multiple assessments had been carried out on the same day for some people and judgements about people’s capacity had not followed the correct process. Some assessments contained contradictory information and we were not assured people’s consent had been accurately obtained. We also identified circumstances where MCA assessments should have taken place, however these had not been considered. This meant people were at risk of receiving care and treatment they, or their legal representatives, had not consented to.