Sir Aubrey Ward 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 Good. At this assessment the rating has changed to Requires Improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

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 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.

Pre-assessments of people’s needs were carried out when people moved into the home. However, although subsequent reviews were unclear as to whether full reviews of people’s needs had been undertaken, or whether a desktop review had taken place instead. People and their relatives told us they were not included in care planning or subsequent reviews.

Reviews were not always completed on a monthly basis in line with the providers policy. For example, 2 people’s care reviews contained the same entry for every review carried out since August 2025. One person’s care plan stated their fluid intake should be monitored but did not contain their desired target of intake. Other people’s care plans did not contain updated information such as incidents of harm they had recently experienced, or what medicines they were taking. Another person’s care plan had not been reviewed for over 2 months. We also identified a person who had moved into the service did not have any risk assessments or care plans in place for over a month.

Assessments also contained out of date information. For example, 1 person's care plan stated they had recently experienced severe burns; however, we established that the burns had been sustained in 2025 and had since healed. This information had not been updated to accurately reflect the person's current needs and circumstances.

We gave feedback to the provider, and they told us staff will undertake re-training around care planning and recording.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

We observed people did not always have easy access to fluids during our visits to the service. We observed a person to only be offered a small amount of fluid on the second day of our visit. People’s fluid logs were not filled in accurately, in some instances showing that during a heatwave, 3 people had not been offered any fluid at all. We did not observe people to be visibly dehydrated; however, we requested the service arrange medical review for people affected. The provider acted immediately. We observed staff attempting to assist 1 person to eat whilst in a poor position, putting them at increased risk of choking. Staff had not received appropriate training or had sufficient guidance in place to support people with behaviours that communicated distress. We gave feedback to the provider, who took action to organise reviews of people’s care and provide training to staff by a specialist dementia nurse.

However, staff used national tools to assess whether people were at risk of malnutrition and skin breakdown. Staff sought medical advice for people who experienced pressure damage related injuries. People’s weight was monitored, and staff offered fortified snacks to ensure people maintained a healthy weight.

The 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.

Staff described escalating concerns to senior carers for referrals to the GP or district nurses if they required extra support with their health however, these were not always escalated to leaders within the service to make the referrals. Leadership within the service could not be assured all incidents and falls had been escalated to healthcare services, as systems and processes around reporting safety events were not embedded. A professional shared their experience of handovers from staff. They told us, “We mostly get good handovers, but we frequently get a response of “I don’t usually work on this unit so I don’t know anything about the person,” however, acknowledged that staff always provided information at their request.

Staff told us they always completed handovers between shifts, ensuring each staff member had allocated responsibilities. Staff were seen to support people with appointments with the GP or district nurses during our visits.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

People were supported to access referrals to the dietitian, speech and language therapy (SALT) and older people’s mental health teams via the local GP. The area manager shared an example where a person was supported to access a private dental service to obtain new dentures when theirs were lost. This meant people experienced improved health and nutrition wellbeing through timely access healthcare services.

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.

The provider's approach to monitoring outcomes was not always effective. Emotional wellbeing, physical health outcomes and people's overall quality of life were not routinely reviewed. Management were unaware of occasions when hydration targets had not been met and were not always aware of people's emotional distress. Reviews of care did not consistently contain up-to-date information about people's physical health needs, emotional wellbeing or outcomes achieved, limiting management's oversight of people's wellbeing and progress.

However, we observed a range of activities taking place within the service, including a choir, games and use of a large electronic tablet for activities such as word searches. People and their relatives spoke positively about these opportunities. Comments included, “The staff and activities like painting are really good,” “there are activities every day,” and “I do all the activities I can but stop at bingo and monopoly. Singing, Zumba, watching the football, and bowling, all very good.”

While people enjoyed the activities available, records did not evidence how people were able to access stimulation when they were unable to leave their rooms or beds for health reasons. Staff told us activities were not always accessible for people who had advanced dementia. The provider's monitoring systems did not consistently assess or record the impact this had on people's emotional wellbeing, quality of life or overall outcomes.

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

Mental Capacity Assessments had not always been completed in line with the Mental Capacity Act 2005. Although they contained very clear information about the decision to be discussed, and an accurate record of the conversation, they did not always contain sufficient detail about how assessments had been undertaken. For example, records did not consistently demonstrate whether people were supported to make decisions at the most appropriate time, in a distraction-free environment, or with any communication support they may have required. Assessments showed people were given opportunities to retain information, and staff recorded the outcomes of capacity assessments and any associated best-interest decisions.

Records relating to consent to care had been signed on behalf of people by staff rather than by the person themselves. We provided feedback to the provider about this. The provider advised that this was a limitation of the electronic care system in use; however, they acknowledged the need for alternative documentation to evidence and record people's consent appropriately and ensure clear and accurate records were maintained.

People confirmed staff asked them for their consent to provide support with care needs. We observed staff respecting people’s wishes when they declined support. People and their relatives did not express any concerns regarding staff acting without their consent.