Sir Aubrey Ward House

Sir Aubrey Ward House is a residential care home providing accommodation and personal care for up to 60 people aged 65 and over. Twenty nine people were living there at the time of the inspection.

People can be accommodated in one of four separate wings, each of which has separate adapted facilities. One of the wings specialises in providing care to people living with dementia. Two wings were not in use at the time of this inspection.

People’s experience of using this service and what we found

Quality monitoring and risk management had improved to protect people from the risk of harm and abuse. We found staff had not routinely followed some safe procedures such as testing water temperatures and documenting catheter care checks. These areas had not been identified through checks and audits. The registered manager and quality manager took immediate action to address these gaps.

People’ emotional and physical needs were assessed. We observed and people told us staff were knowledgeable and skilled in meeting people’s needs. Some care records did not always demonstrate how staff followed people’s care plans when people were in distress. The registered manager provided an action plan about how to improve this with staff.

People using the service and their relatives were positive about the management of the service and standards of care people received. For instance, “The home has much improved since [the registered manager] arrived and I hope they stay”, “I am amazed how good staff are. Nothing could go wrong. I think it is [well managed]. There are good days and bad days”, “I have no concerns, [family member] has a wash or a bath and always looks presentable and I feel they are safe without a doubt”, “The carers are friendly and polite, they are welcoming and make the family feel relaxed and it feels like home to me. Sometimes I just turn up and have my dinner with them”, “It couldn’t be better [here]. The girls are very good. They look after you. Anything you want, you just call” and “[Staff] listen. They get to the stage when they just know”.

The home was comfortable and accessible to people and was well maintained and clean. Hygienic practices and COVID-19 protocols were followed to prevent infections. People were supported to access the community and receive visitors; “We are able to visit [family member] pretty much as normal except we sign in and the home still likes us to wear a mask”.

Medicines were managed safely. People were given their medicines as prescribed. Care plans had the necessary medicines risk information about prescribed medicines.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 13 December 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 10 December 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced focused inspection of this service on 27 October and 3 November 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, safeguarding, good governance, the management of complaints, reporting statutory notifications to CQC, nutrition and hydration, dignity and respect, need for consent and enough suitable staff.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sir Aubrey Ward House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Sir Aubrey Ward House is a residential care home providing accommodation and personal care for up to 60 people aged 65 and over. Thirty eight people were living there at the time of the inspection.

People can be accommodated in one of four separate wings, each of which has separate adapted facilities. One of the wings specialises in providing care to people living with dementia. One wing was not in use at the time of this inspection.

People’s experience of using this service and what we found

There had been several changes to staff since the previous inspection, including managers. We saw appropriate checks had been carried out for temporary and permanent staff before they started working at the home. We received mixed feedback from people we spoke with or who contacted us. Some spoke positively about the support they or their family members received, whilst some relatives told us the changes to staffing meant there was often a lack of continuity in their family members’ care.

Some staff had worked excessive hours at the home recently to cover other staff vacancies and unplanned absences. We received concerns about staff cover at night time. A community healthcare professional told us about five occasions when they had visited and they felt there had not been enough staff to support people. On the second day of the inspection, the manager took steps to increase staffing levels in one part of the home where people had higher care needs, to address this.

We found staff, including senior staff, did not have knowledge of people’s past histories because they had not worked at the service long enough. Community healthcare professionals expressed concern about this as staff were unable to advise them about people’s medical histories. We observed staff to be focused on tasks rather than responding to the needs of people. For example, we heard staff comment to each other about how cold it was in a lounge where people were sitting. No one attempted to provide people with blankets, warmer clothes or adjust the heating. Staff did not always promote people’s dignity in the way they supported them. We observed people who were exhibiting signs of distress were either ignored or given basic and non-meaningful responses by staff.

People were not supported to be protected from abuse. The provider and staff failed to recognise when people were subjected to avoidable harm, events which had caused injury or harm to people had not been reported to the local authority safeguarding team for them to investigate. This meant there was a danger the event could reoccur.

The provider had systems to support staff through supervision, appraisal and training. However, we found people were cared for by staff who had not received regular supervision or an appraisal, to help them develop professionally. Training was being brought up to date by the provider to ensure staff had the skills they needed to meet people’s needs.

People were not fully protected from the risk of fire. Checks and servicing took place of fire safety equipment. However, we found not all staff, particularly night staff, had been instructed on what to do in the event of a fire. This meant they may not know how to safely evacuate the building. The provider had started to take steps to address this whilst the inspection was on-going.

People were not protected from the risk of infection. Staff did not follow good practice to prevent cross-infection. For example, there was no separation of clean and contaminated items in sluice rooms. Laundry and sluice areas were cluttered, making them difficult to keep hygienic. There was a risk infections could spread from person to person in these conditions. The provider was unable to demonstrate any infection control audits had been carried out at the home, to show they had been monitoring practice during the coronavirus pandemic.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People did not routinely have their nutritional and hydration needs met. We found people were at risk of weight loss and some people had experienced actual weight loss.

We were unable to see that complaints were managed effectively. Records we were provided with were not sufficient to show complaints were always investigated and a response sent to the complainant.

People told us communication with the home was poor. Feedback from people and their relatives included “I think I’m losing my marbles because all these things are happening and [the management] just brush over it” and “We don’t know where the managers have disappeared to…you get to know them and then [they’re gone].” The provider failed to report to us all events they were legally required to. The provider failed to ensure they had effective systems in place to comply with the regulations. Audits carried out by senior were ineffective and did not drive improvement. Records management at the home was poor, it was disorganised, inaccurate and contradictory. The provider had failed to act on our previous feedback about the quality of the care provided. We found people were experiencing poor quality care which had the potential to put them at risk of harm.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Requires Improvement and there were breaches of regulations regarding safe care and treatment and governance of the service (report published 25 January 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made and the provider was still in breach of regulations. The provider has not achieved a good rating in the safe domain for the last five consecutive inspections.

Why we inspected

We received concerns in relation to management of the home, the high number of unwitnessed falls, unreported safeguarding concerns and the management of people’s health and staff support. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe, effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sir Aubrey Ward House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to how people are supported to receive dignified care and how they are supported in line with the Mental Capacity Act (2005). We also have concerns about the management of risk and how people are supported to meet their nutritional needs. Other areas of concern are staffing levels and how staff are deployed, supervised and trained, safeguarding people from abuse, and the provider’s oversight of the service to ensure the service is well run and regulations are met.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

About the service

Sir Aubrey Ward House is a residential care home registered to provide personal and nursing care up to 60 people aged 65 and over. At the time of the inspection there were 50 people using the service.

The service accommodates people across four floors each of which has separate adapted facilities.

People’s experience of using this service and what we found

We received mixed views from relatives about the care provided. We also received mixed views from staff we spoke with. However, all stated things were improving since the appointment of the new manager.

We checked food and fluid charts and medicine charts during our visit. We found these were inconsistent and did not always record up to date information. For example, some food and fluid charts we saw did not record the amount of food and fluids people had consumed consistently. Some charts showed people had only consumed one meal throughout the day and fluids were not recorded, some charts recorded people had been offered very little fluid throughout the day. In addition, some charts were blank. Medicine charts were checked by another member of staff who had recorded ‘no discrepancies’ however, we found this not to be the case. Some signatures were missing, and two people had not received their medicine due to lack of stock. We followed this up the manager at the time of our inspection. The manager confirmed this would be addressed with immediate effect.

Accident and incidents were recorded but not always analysed to enable lessons to be learnt.

The provider had good systems in place to prevent the control of infection and was following government guidance in relation to the Covid-19 pandemic.

Several senior staff had left, and the manager was recruiting to fill these roles. We saw there were adequate staffing levels to meet the needs of people using the service. The manager told us recruitment was ongoing and they were always available to ‘help out’ when required.

Staff we spoke with told us there had been a culture of poor behaviours of senior staff and not all staff felt able to speak up to voice their opinion about the service. We were told this was being broken down gradually, but there was still a way to go.

The governance systems were not always effective. For example, medicine auditing, food and fluid charts and care plan auditing. However, the provider was in the process of introducing a new computerised system to monitor these systems more robustly.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 30 April 2019) and there were multiple breaches of regulation. During this inspection we found the provider was still in breach of Safe Care and Treatment and Good Governance.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found sufficient improvements had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about staffing levels and safe care and treatment. We also needed to check what improvements had been made since the last inspection to address the breaches of regulations. A decision was made for us to inspect and examine those risks. We undertook a focused inspection to review the key questions of safe and well led only.

We have found evidence that the provider needs to make improvements. Please see the key question safe and well led sections of this report.

You can see what action we have asked the provider to take at the end of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sir Aubrey Ward House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified continued breaches in relation to safe care and treatment and good governance at this inspection.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

About the service: Sir Aubrey Ward House is a residential care home that was providing personal and nursing care to 58 people aged 65 and over at the time of the inspection.

People’s experience of using this service:

Records at the service were not always robust and required improvements to ensure accurate information was recorded in relation to people’s care.

• People’s confidential information was not stored securely.

• Care plans we viewed were not always consistent with the care and support being delivered.

• Medicines were not always managed effectively.

• Systems and management plans were not always in place to manage the risks associated with people’s behaviour.

• Staff were provided with training and supervision. However, some staff we spoke with told us they could not remember when they last had a supervision.

• The services infection control policy was not upheld. We saw care staff with long fingernails, and wearing rings and several bracelets.

• People told us they enjoyed the food at the service. Where people were at risk of malnutrition appropriate steps were taken.

• The environment was adapted to suit the needs of people living there.

• People were treated in a dignified and caring way.

• End of life care was discussed with people and where appropriate their families.

• Activities were available for people to avoid social isolation.

• Complaints were recorded and responded to appropriately.

• Systems were in place to review the quality of care including feedback questionnaires and meetings.

• Where appropriate notifications were sent to CQC.

Rating at last inspection:

• At the last inspection the service was rated Good (the report was published on 25 June 2016).

Why we inspected:

• This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Follow up:

• We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

We previously inspected the service on 2 and 3 June 2016. The service was rated ‘good’ overall at that time. However, there was one area where a regulation was not fully met. This was in relation to the management of people’s medicines. We made a requirement for the provider to improve practice. They sent us an action plan which outlined the measures they would take to make improvements. This focussed visit was to check the improvements had been made and only covered the ‘safe’ domain.

Sir Aubrey Ward House provides care for up to 60 older people, including people with dementia. Fifty nine people were being cared for at the time of our visit.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We saw staff interacted well with people; there were lots of smiles and laughter and the busy morning routine was managed in a calm and organised manner. People told us staff were around when they needed them. One person said they were happy at the home and added “Most of the staff are friendly. There’s the odd one I don’t get on with. There’s no issues, just different personalities, some you click with.” Another person said “The girls are good, I couldn’t do their job. They’re very busy.” People told us they received support from staff who regularly worked at the home and understood their needs. One person said “That makes a big difference. You’re not having to repeat what you like all the time, they know you.”

Risk assessments had been written to identify areas where people could potentially come to harm and to minimise the likelihood of this. For example, when they were assisted with moving. People had the equipment they needed to get around the building, such as walking frames and wheelchairs. Grab rails had been provided in bathrooms and corridors to help people manage independently wherever possible.

We spoke with an activity organiser. They ran a morning exercise group for people who had strokes. One of the people who attended the group told us “I used to use a walking stick when I first came here but now I don’t need it.” They said this was because the exercises had been helpful in improving their strength. We saw the person walked around safely and steadily.

At the last inspection we made a recommendation for staffing resources to be re-assessed, to ensure there were sufficient staff to meet people’s needs at all times. We discussed staffing levels with the registered manager and regional director to see if any changes had been made. They told us additional staff hours had been agreed for the service and these would be advertised. This would provide more flexibility in how staff were allocated to areas of the home that were particularly busy.

Improvement had been made to the management of medicines. Accurate records were now maintained and medicines rooms and trolleys were kept secure. We made a recommendation at the last inspection for the service to follow good practice in the application of transdermal (skin) patches, to ensure a different area of the body was used each day. This was to avoid skin irritation. We saw charts were now used to record where skin patches had been applied. These showed rotation on the body, which reduced the likelihood of skin becoming sore.

People were protected from the risk of unsafe premises. The building was well maintained and complied with gas and electrical safety standards. Evacuation plans had been written for each person, to help support them safely in the event of an emergency.

We found although staff were trained to ensure they provided safe care to people, update courses had not been undertaken in line with the provider’s policy. For example, manual handling training needed to be updated each year and safeguarding training every two years. We could not see that people’s care was directly affected by this but it could mean staff were not up to date with new ways of working.

We have made a recommendation for staff training to be updated in line with the provider’s policy.

We previously inspected the service on 26 June 2013. The service was meeting the requirements of the regulations at that time.

Sir Aubrey Ward House provides care for up to 60 older people and people with dementia.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

We received positive feedback about the service. Comments from people included “When you loose your health and your own home, you are glad to come somewhere like this,” “It’s quite nice here,” “You don’t have to do the shopping; you can have pets if you want to,” and “I’m certainly happy with the service.” One person told us “It’s a good place to be as you are always with people.” A social care professional described the service as “A very well run home” and added “I can’t really fault them.” A relative said “If there was some award you gave out I would say could you please give it to Sir Aubrey Ward. They have a dedicated team of carers and staff. All I can say is that if it had not been for them, my mother would not be here today.”

People were protected from the risk of harm. There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns.

Staff were recruited using robust procedures to make sure people were supported by staff with the right skills and attributes.

Staff received appropriate support through a structured induction, regular supervision and an annual appraisal of their performance. There was an on-going training programme to provide and update staff on safe ways of working. We have made a recommendation for staffing resources to be re-assessed, to ensure there are sufficient staff to meet people’s needs at all times.

Care plans had been written, to document people’s needs and their preferences for how they wished to be supported. These had been kept up to date to reflect changes in people’s needs. People were supported to take part in a wide range of social activities.

Staff supported people with their healthcare needs to keep healthy and well. We found staff did not always follow best practice in the management of people’s medicines. We have also made a recommendation about the recording of transdermal (skin) patches, to ensure a different area is used each day, to avoid skin irritation.

People’s complaints were listened to and responded to. The service was managed well. The provider regularly checked quality of care at the service through visits and audits. The registered manager was skilled and experienced and was assisted by a team of senior staff. There were clear visions and values for how the service should operate and staff promoted these. For example, people told us they were treated with dignity and respect and we saw they were given choices.

Records were generally maintained to a good standard and staff had access to policies and procedures to guide their practice.

We found a breach of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to medicines practice. You can see what action we told the provider to take at the back of the full version of this report.

We returned to the service on 26 June 2013 to check whether improvements had been made. We looked at medication practice in two parts of the home. We found staff were now following the arrangements for the recording of medicines.

We saw there were good infection control practices at the home. We found the building to be clean and hygienic. Staff had undertaken training on infection control and had procedures and guidance to refer to. A five star/very good rating had been awarded by the Food Standards Agency in October 2012, for food hygiene standards.

We had concerns about medication practice at our last inspection. We found improvement to some areas of medication practice on this occasion. Records of medication administration were legible and there were specimen staff signatures and initials to help with auditing. We saw medication was stored safely and staff who handled it had received training. However, there were some inaccuracies in records associated with medication practice.

There were enough staff to ensure people's needs were met. The staff we met were experienced in working with older people. We saw they had access to a range of training courses to keep their skills and knowledge up to date. We found staff were attentive to people's needs and took an interest in their wellbeing.

People and their relatives had the opportunity to visit the home before they moved in to ensure it met their needs and expectations. A relative told us they looked at many homes and "this one stood out." They said their mother's key worker assessed her needs before she moved into the home.

Care plans contained detailed information about people's individual needs. They were reviewed regularly to ensure care provided was current.

People said they felt safe and staff looked after them well. They knew who to speak to if they had concerns. One person said 'if I wasn't happy I would go to the person in charge but I've never had to complain.' Another said 'I would tell my key

worker if I wasn't happy.'

Daily activities were provided to those who wished to take part. These included trips out into the community as well as in house activities. One person told us "we have bingo, simple exercises and we have the odd trip out to Marlow and High Wycombe."

We found poor practices in relation to the management of medication which failed to ensure people were protected against risks associated with the unsafe management of medication.