Sir Aubrey Ward House

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 as 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 service was in breach of legal regulation in relation to people’s safe care and treatment, the ways people’s medicines were managed safely, safeguarding people from abuse, and infection prevention and control.

This service scored 47 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate safety events. Lessons were not learnt to continually identify and embed good practice.

Staff reported safety events in people’s daily care records, however, these were not formally escalated via the provider’s reporting system or investigated by senior leaders. For example, several people had experienced multiple falls over a three month period. These had not been formally reported, investigated individually or as a whole to assess trends and themes. This meant people experienced harm from multiple reoccurrences as the provider failed to identify actions or lessons learned.

The service held some records of learning from incidents from within the home, and from other services run by the provider, however, not all staff had signed the records as understood. Systems and processes were not in place to identify reoccurring safety events leading to physical harm sustained by people, their relatives and staff working for the service.

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.

People were supported to access healthcare professionals such as the GP, and district nurses within the service. We observed staff accompanying the GP to support people with communicating their care needs. A professional told us, “I usually handover to the senior carers on the unit”, which ensured people experienced safe continuity of care.

Whilst people told us they felt safe, the provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Records evidenced that people living in the service had suffered emotional and physical harm. This included pressure injuries, as well as injuries resulting from verbal and physical altercations between people using the service. These had been recorded on people’s daily notes, but not formally via the provider’s incident and accident reporting system, meaning they had not been investigated by the leadership team.

Staff had completed online safeguarding training and told us they would report concerns to senior staff within the service; however, staff were not confident about local processes and reporting externally. This meant the provider missed opportunities to share concerns with the local authority or work with healthcare professionals to protect people from harm. We gave feedback to the provider and asked them to ensure staff refreshed their knowledge in safeguarding and local processes.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. The registered manager informed us they were re-applying for Deprivation of Liberty Safeguards (DoLS) for people as records held did not provide assurance that applications were being monitored and conditions met.

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

Risk assessments were not always in place or did not provide staff sufficient guidance to support people to manage risks to themselves. For example, 1 person did not have a risk assessment in place for managing behaviours that communicated an emotion or distress. Staff told us they had requested additional training and guidance to enable them to support this person effectively, as they lacked confidence in managing their needs. Staff reported they had not received training in dementia care, or in supporting people who may experience behaviours associated with dementia.

Three people’s falls risk assessments did not contain up to date information regarding recent falls, or provide staff sufficient guidance to support them, or detail medical advice previously sought. This meant people were put at increased risk of harm.

However, staff supported people to take positive risks. A person’s risk assessment included detail about supporting them to have their favourite drink in bed. People consistently told us they felt safe and received good care from staff. We observed staff supporting people to move between areas within the service. Risk assessments were in place to guide staff in managing infections and viruses. Some assessments were personalised and detailed the medicines people were prescribed, as well as the support staff should provide if an infection or virus occurred. Risk assessments supported people to stay safe while promoting their freedom of movement within the service. This meant people were supported to manage risks by staff using the least restrictive measures necessary.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider carried out checks of the environment and equipment used to ensure people’s safety. The provider had identified concerns relating to fire doors which they had escalated to the landlord. Fire drills had been carried out regularly, with improvements identified and monitored. The responsible person acknowledged that more focus was required on completing fire drills at night time. People’s Personal Emergency Evacuation Plans (PEEPs) contained basic information regarding people’s needs and their location within the building.

The maintenance lead carried out daily and weekly walkarounds of the service to identify any environmental concerns. A hot weather risk assessment had been implemented, including installation of air conditioning to keep people cool, and ensure people used shaded areas of the garden. People told us, “The home is comfortable, “The home has very good air conditioning and you can go into the beautiful garden,” and “I’m very happy with [the service], there is a lovely garden to sit in.”

Staff checked temperatures of people’s rooms and communal areas to ensure they remained safe.

The provider did not always make sure there were enough qualified, skilled and experienced staff. However, staff worked well together to provide safe care that met people’s individual needs.

People provided mixed feedback about staffing levels, with some feeling there were enough staff, and others did not. People’s relatives shared concerns about staffing levels at night. For example, a relative told us they had to attend the service at night to help support their relative, due to a lack of sufficient staff to support the person. Another relative told us, “I visit quite regularly and I think at night times an additional carer would be advantageous.”

Staff shared concerns about staffing levels and workload pressures. Comments included, “We’re not able to spend enough time with people in the morning,” “Night shifts are challenging. If we have an incident on another unit, then some units might get left unsupervised so we can help,” and “We don’t have enough staff on [unit], as so many people need supervision to prevent falls, or incidents.”

Staff also shared concerns about duties to be completed on night shifts that reduced time available to support people in a person-centred way. For example, staff told us it was difficult to make people late night meals and drinks as part of their bedtime routine, and support people who required 2 staff members to support them with personal care. We asked the provider for clarification regarding responsibilities of staff on night shifts. They confirmed extra checks had been implemented as a result of learned lessons from previous incidents in other services, however, had not re-evaluated the staffing levels on night shifts since these had been implemented.

We have asked the provider to evaluate staff deployment at night to ensure people’s needs are met.

Systems were in place to ensure staff had training and were checked to ensure they were competent. Where required the provider was able to quickly support staff with refresher training. We noted this had been completed after our feedback to the provider on infection, prevention and control. Staff had 1-1 meetings with a line manager to discuss their professional development.

People were supported by staff who had been checked to see if they were suitable to work with them. All new staff were subject to a Disclosure and Barring Service (DBS) checks which provided information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified concerns around Infection prevention and control (IPC) during our visits to the service. People were not routinely offered hand hygiene opportunities before eating meals.

We observed a person being served their meal on the seat of their assistive aid, which was visibly unclean. The person dropped their cutlery on the floor, which was then promptly given back to them by staff to continue eating. A table was brought in for the person to rest their food on, and the person then continued to eat their food with their hands, and staff did not intervene. The table had been used previously by another carer who was assisting another person to eat in the corridor. After the table was removed, we then observed the carer kneeling on the floor, with the person’s plate resting on the carer’s seat, assisting the person to eat.

The environment wasnotably unclean, with floors, walls, surfaces and furniture sticky and visibly stained. A rubbish bin was found open, with discarded waste exposed and accessible to people within the communal area, presenting a potential ingestion and infection risk. A used pot containing urine was found in a person’s bathroom, and a used cardboard container containing waste and ice lolly residue was identified in an unlocked cabinet accessible to people in the communal area.

Staff uniforms and tabards worn to carry out specific medicine administration duties were visibly stained and not clean. Staff were seen wearing excessive jewellery and nail coverings, which is not in line with good practise for IPC. Foods were not consistently labelled when they had been opened, so staff could not be assured that people were protected from the risk of food-borne infections. We identified some out of date items of food in the kitchen store, although the chef confirmed these had not been used to cook anything for a “long time.”

During our first visit, staff did not practise routine hand hygiene, particularly before serving food at mealtimes. We gave feedback to the provider, and when we returned for a second visit, staff were observed to be regularly washing their hands. The registered manager told us, “We have re-issued infection prevention control training for everyone. We have also asked staff to re-complete hand hygiene competency checks.” Staff were also seen to be offering people the opportunity to wipe their hands before mealtimes during our second visit.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People who lived with dementia and occasionally showed signs of distress were not always supported in a way which maximised their opportunity to feel calm and secure. Two people were prescribed medicine to support with distress. However, records relating to when medicines should be administered were not always clear. Staff shared concerns with us about when these medicines should be administered, as they recognised that once 1 person became too distressed, they were then unable to take their required medicine.

Where people had been prescribed medicines for occasional or 'as required' (PRN) use, the provider had not consistently ensured that appropriate PRN protocols were in place to guide staff on how, when, and why these medicines should be administered. As a result, medicines were not always managed safely or in accordance with national guidance. We found that PRN protocols were either missing or did not contain sufficient information to guide staff in the safe and consistent administration of PRN medicines.

People who used emollients or other flammable medicines did not have care plans and risk assessments in place to alert staff on how to prevent harm due to fire or burning. People who were prescribed blood thinning medicines which placed them at greater risk of bleeding did not always have a risk assessment in place to guide staff on how to prevent excessive bleeding.

Records relating to medicine administration did not always follow best practice guidance. For example, records for people who were prescribed creams or emollients did not contain clear guidance on what cream they were prescribed.

Systems had previously been in place to monitor and audit medicine management; however, they did not identify the issues we found, and audits had not been completed since May 2026.

However, people were supported by staff who had received training in the safe administration of medicines. People and their relatives told us they had no concerns with how people received their medicines. We observed staff supporting people to take their medicines in a safe way.