Aquarius Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of legal regulation in relation to providing safe care and treatment. Sufficient improvements were not found in this assessment and the provider remained in breach of this regulation.

This service scored 59 (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 always a proactive and positive culture of safety. There had been improvements in how safety events concerning people were investigated. But safety concerns in the environment had not always been acted on in a timely manner.

Although staff told us they were confident to report any accident, incidents or safety concerns they had not always recorded bruising identified on a body map so they could easily be identified. The provider told us they were monitoring the situation and giving staff support to complete the necessary documentation and any safeguarding referrals as appropriate.

Systems were improving to investigate and review these significant events. This meant appropriate actions could be taken to maintain people’s safety. An incident took place during between two people during our assessment. Medical attention was given as required and a record made of the circumstances in people’s care notes. People were asked what had occurred but were not able to give a comprehensive account. We suggested that the CCTV on communal areas be reviewed to establish what had happened. The provider said they had not done so on this occasion, but would take this advice on board going forward.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had established relationships with a range of health care professionals including community nurses, speech and language therapists and dementia specialists. Care plans had been reviewed to ensure referrals had been made to health professionals in a timely manner.

Hospital passports were in place to support people when they needed to go to hospital or attend clinic appointments. These records contained all the necessary information for external professionals to know about the person’s health.

People were supported to maintain their health, attend appointments both inside and outside of the service. Relatives told us healthcare professionals were contacted when needed.

The provider worked with people and partners to understand what being safe meant to them and the best way to achieve that. Staff understood how to ensure people lived in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff had received training in how to recognise and report abuse and access to the provider’s safeguarding and whistle blowing policies. Staff knew how and to whom they should report concerns both internally and also to external agencies if their concerns had not been taken seriously. The provider had reported safeguarding concerns to the local authority who is the lead agency for safeguarding.

People told us they felt safe at the service. A person said, “Yes, I do feel very safe and I really like (named staff). He is so kind to me.” Relatives said their family members were safe living at the service. They said this was very important to them due to their family member’s health and medical conditions.

The provider did not always work well with people to understand and manage risks. Staff were not always guided how to provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider had continued to fail to have effective systems in place to identify, monitor and manage risk. At our assessment in January 2025 we had identified continued shortfalls in risk management. The provider told us before this assessment, that these shortfalls had been addressed. However, we found that this was not the case.

The provider had engaged an external consultant to review risk management. They had concluded that guidance about people’s risk assessments were missing or lacked enough detailed information for staff to know how to keep people safe. There remained shortfalls in risks and guidance around people’s medical conditions, eating and moving and handling. When risks had been assessed, these were not linked to people’s care plan to guide staff on the actions they needed to take to keep people safe. For example, a person needed to sit up before and after they ate due to their risk of choking. This information in the person’s risk assessment was not in their care plan for staff to follow. This put the person at risk of harm.

Some people used a catheter. A catheter isa thin, flexible tube used to drain urine from the bladder into a collection bag. There are risks associated with using a catheter such as infections, blockages and leaks. Staff were not guided about these risks, how to identify them or what to do if they occur. Staff had not received training in catheter care. After the site visit the provider sent training certificates to evidence that staff had now undertaken training in this area.

Each person had a personalised evacuation plan with guidance for staff and emergency services on the support they would need to evacuate the building safely in the event of a fire. There was a portable kit of essential items for staff to grab by the front door in the event of a fire.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider previous employed a member of staff to manage maintenance but had changed to external contractors. Contactors repairs had not been carried out in a timely manner. A fire door was broken and so it would not close in the event of a fire and a broken socket was exposing electric wires, which was hazardous. The provider submitted evidence during our assessment that these hazards had been remedied and we were assured by this response. In addition the grouting in the shower room had been roughly repaired, which meant it could cause skin tears when people used the shower. There was also a hole in a shower room floor which was an environmental risk. There was also general wear and tear to the paintwork and walls throughout people’s home which did not meet with their expectations of a dignified environment. The provider informed us plans were in place to address these shortfalls but did not give us a timescale.

Essential servicing had taken place such as the maintenance of gas, water and electricity. Regular checks and maintenance were carried out of fire fire-fighting equipment and moving and handling equipment. Staff practiced fire evacuation to ensure they were competent they knew what to do in the event of a fire.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The provider had startedusing a dependency tool to assess people’s care needs with the number of staff required during the day and night to meet them. As a result, there were 4 staff available to support people during the day and 2 at night. However, we observed staff were busy in the morning and a number of call bells were left to ring for over 5 minutes. A call bell rang for 15 minutes. When staff went to see the person, they wanted pain relief. The provider told us there was an issue with staff receiving calls (from the call bells) on their work telephones, resulting in staff not being aware that people were calling them. The provider sought advice during our visit and commenced resetting staff’s phones, where they received calls, as advised. Relatives reassured us that call bells did not usually ring for long.

Staff told us they were under pressure due to the high turnover of staff. Staff told us it took time to support new staff to learn their roles and get to know the people they supported. They said that when 1 or 2 members of the staff team were new this impacted people as they were rushed and not able to give people the time and quality of care they deserved. Relatives confirmed there was a high turnover of staff and they had more confidence in some staff’s skills and knowledge to support their family member than other staff members. At the time of our assessment the provider was in the process of recruiting additional care staff.

Staff training was not comprehensive as although it included training specifically for people with a learning disability, and the specific needs of older people living with dementia, it did not include catheter care. The provider was not aware of this omission but acted once it had been brought to their attention. They sent training certificates to evidence the whole staff team had received training in catheter care.

New staff completed an induction, including shadowing experienced staff, observations, completing essential training and the Care Certificate before working on their own. The Care Certificate are the standards employees working in adult social care need to meet before they can safely work unsupervised. The provider had implemented a system to ensure staff received supervision and discussions about their development.

The provider had undertaken necessary checks for new staff such explanations for any gaps in people’s employment history and Disclosure and Barring checks (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. However, they did not have an effective system for verifying all work references. The provider started to address this shortfall during our assessment. All these checks help employers make safer recruitment decisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

Staff had received infection prevention and control training and understood what to do to mitigate infection risks. There was a daily cleaning schedule including deep cleaning of people’s bedrooms. Housekeeping staff employed on the day of the assessment ensured the service was cleaned to an appropriate standard. There was an adequate supply of personal protective equipment (PPE) such as gloves and aprons situated around the home. We observed staff using PPE appropriately throughout the service.

Relatives told us the service was always clean and smelled fresh when they visited. A relative told us when staff dropped their family member’s medicines on the floor by accident, they disposed of them and gave them new medicines. They told us this was good infection control practice.

The service had a 5-star food and hygiene rating, indicating that hygiene standards were ‘very good’.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff who supported people during the day and night had been medicines trained to ensure people could receive their medicines as prescribed by their doctor. Clear records were kept of when people needed their medicines and when they were given. Staff were aware that some medicines needed to be given at specific times to ensure their health.

Relatives said that people were supported well with their medicines management. A relative told us their family member sometimes refused to take their prescribed medicines and that staff dealt with this very well. They said on these occasions, staff would leave their family member and go back later and keep trying until they took all their medicines.

There were protocols in place for people prescribed medicines to be taken when needed. Some protocols in relation to medicines related to constipation were not as clear as they could be and this was addressed during the assessment. Body maps guided staff to which part of a person’s body topical creams should be applied. Where people had patches applied to their skin for pain, staff regularly rotated them to help keep people’s skin healthy.

Medicines were stored securely, separately for each person to minimise errors and at the correct temperature to ensure they were fit for purpose. Medicines were dated on opening to ensure they were used with the time period that they were effective. There was a clear audit of medicines coming into and leaving the service. This included medicines which are at higher risk of misuse and therefore need special storage and closer monitoring.