Aquarius Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. Sufficient improvements were not found in this assessment, and the provider remained in breach of this regulation.

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The provider’s vision and strategy had not always resulted in a positive culture at the service.

There had been a change in the management of the service since our last assessment. The provider had registered as the manager of the service. They were supported by the deputy manager and head of care who had worked at the service for a long period of time. Relatives said there had been a number of changes in management and they had not always been told about changes in the management structure in a timely manner.

There was a mixed response from staff about the culture of the service. Staff told us there were no formal systems for staff to be shown appreciation for their roles. Some staff described a positive culture where they felt supported and were given praise. A staff member told us, “Management are brilliant. They are always trying to keep us on our toes.” Other staff felt disempowered as ways of working kept changing, staff kept changing and they felt under pressure if they did not complete all their assigned tasks. Comments included, “We are not well appreciated. There is no empathy for staff and we are working under pressure."

The provider had leaders who understood the context in which they delivered care, treatment and support. However, leaders did not always have the skills, knowledge, experience to lead effectively as they had not addressed all the shortfalls from the last assessment.

The provider acknowledged there had previously been a lack of oversight of the service and had stepped into the role of registered manager to address these shortfalls. The management team were motivated to make necessary changes but these had not been acted on in a timely manner and there remained shortfalls in service delivery. This included care plan guidance and actions to minimise potential risks to people.

Most relatives were positive about the management team. A relative told us, “We have had a really supportive experience. We have had some issues but they (the management team) have always been open and honest.” A number of relatives mentioned a specific member of the management team being extremely helpful and kind and ‘going the extra mile’. Other comments included, “She can sound a bit abrupt although I think her bark is worse than her bite” and “It is not always easy to get hold of a member of the management team on the phone."

The provider did not always foster a positive culture where people felt they could speak up and their voice would be heard.

The provider had a ‘Freedom to Speak Up’ policy which provided protection for those who spoke up, ensuring they would not suffer detrimentally for raising their concerns.Most staff felt able to voice their views at team meetings or supervisions. A staff member told us, “We are a small team so everybody knows everyone and is welcoming. It’s like a family.” However, some staff told there was no point in speaking up as their views would not be listened to. A staff member told us, “You do not have a voice.”

All staff had attended the last team meeting which showed staff commitment to the service. A programme of staff supervisions had commenced which included looking at staff development.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff had received training in equality and diversity and the service had a diverse workforce. However, we found staff had not always been treated fairly and equitably according to the provider’s policy. For example, staff were expected to work and complete tasks essential to their role in their own time. This included attending staff meetings and undertaking essential training.

Flexible working was in place to support staff, who gave us examples of how this had supported them in relation to childcare responsibilities.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had continued to fail to ensure there were effective governance systems at the service. This was despite sending us an action plan after our last assessment of the service, giving assurance that effective auditing processes had been established.

Auditing processes had commenced in key areas including accidents and incidents, medicines, safeguarding, dignity, infection control, fire and equipment. This had resulted in improvements in the monitoring of accidents and incidents. It had been highlighted that not all staff had developed the correct skills in completing accident forms and they were being supported by the deputy manager. However, audits had failed to identify a hole in the bathroom floor which was an infection control risk and gaps in staff training and knowledge in catheter care. In addition, a care plan audit had only taken place shortly before the assessment and so there had not been time to implement the necessary changes. We found additional shortfalls in care plans such as not identifying the sling sizes used in moving people and infection risks. This meant staff still did not have access to essential information about how to keep people safe, 9 months after our initial assessment in January 2025. Although the provider sent evidence they had addressed some of these shortfalls during our assessment, they had only taken action after we had brought them to their attention.

During our assessment there were delays in people’s call bells being responded to. For example, it took staff 15 minutes to respond to someone who required medicine for pain relief. The provider told us this was a fault with the call bell system. However, they only carried out an audit of the system after we advised them. The audit did not include call bell response times to ensure people were regularly receiving care and treatment in a timely manner.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. The provider had appropriately informed us of events and incidents.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The management team and staff worked to build and maintain relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people. The service had developed partnerships with varied organisations through activities, end of life care and dementia care.

The provider had begun to develop processes for continuous learning, innovation and improvement across the organisation but these had yet to be embedded at the service.

The provider had started to implement processes to ensure the service improved. This included monitoring accidents and incidents to identify any patterns, establishing an auditing system and gaining feedback from relatives and staff.

The provider completed an action plan after our assessment visit setting out the actions they had taken or were taking to address the shortfalls found during the assessment. This included reviewing people’s mental capacity and guidance and medication protocols with regards to constipation.