Sir Aubrey Ward House

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 service was in breach of legal regulation in relation to governance at the service.

This service scored 54 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff spoke positively about their roles and demonstrated a strong commitment to delivering person-centred care. Several staff members had worked at the service for a number of years, providing continuity and experience within the workforce. While staff acknowledged the challenges associated with the recent change in provider and management arrangements, they consistently described a caring and supportive team culture. Staff told us they were proud of the care they delivered and felt their colleagues shared a genuine commitment to achieving positive outcomes for people. Comments included, “I’m quite happy here”, and “I chose to work here as it is open and transparent.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The registered manager had been in post for two weeks at the time of the inspection. Prior to this, the service had been overseen on an interim basis by a member of staff for more than 6 months. Governance systems had not been effective in identifying and addressing concerns within the service. Audits completed by senior leaders had failed to identify a number of the issues found during the inspection, limiting the provider’s oversight and assurance of quality and safety. Leaders told us, “I can only look at what is reported to me,” which demonstrated a reliance on information being escalated rather than proactive monitoring to identify where improvements and support were required.

The registered manager and newly appointed home manager were present throughout the inspection and responded positively to feedback. They acknowledged the concerns identified and recognised where improvements were needed. Staff spoke positively about the new management team and expressed confidence in their ability to drive improvement. Staff described management as approachable and felt the changes in leadership would have a positive impact on the quality of care and support provided.

People did not always feel they could speak up and that their voice would be heard.

Some staff told us they did not always feel listened to, or appropriate action would be taken in response to concerns they raised. One staff member commented, “It would be nice to hear that things are being resolved.” Staff expressed frustration that issues they had previously escalated had not always been acted upon, including concerns that reflected some of the shortfalls identified during the inspection. This indicated there were opportunities to strengthen communication and ensure staff feedback was consistently acknowledged, acted upon, and used to drive improvement within the service.

However, people and their relatives confirmed they were confident in raising feedback if they needed too.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

All staff completed equality and diversity training. We did not identify any concerns around unfair treatment. All staff confirmed they were treated fairly

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.

Systems and processes were not effective in identifying, monitoring or investigating concerns relating to accidents, incidents, adverse events and episodes of behaviour that communicated distress. Records evidenced occasions where such events had been documented in people's daily notes but had not been formally reported or reviewed through the provider's incident management processes. Operational manager audits did not routinely review daily records and, as a result, failed to identify under-reporting of these events. Statutory notifications were not made to the Care Quality Commission in line with regulation. This limited oversight reduced the provider's ability to mitigate risks and safeguard people from harm.

Medicines governance arrangements were not robust. The service had not completed medicines audits since May 2026. Medicines audits completed prior to this identified required actions, but the provider could not be assured these actions had been followed up. Although operational manager audits had been completed in June 2026 and July 2026, these had not identified concerns relating to medicines management found during the inspection. This demonstrated a lack of effective oversight and assurance in relation to the safe management of medicines.

Systems and processes had also failed to ensure records relating to people's care and treatment were complete, accurate, contemporaneous and up to date. For example, incidents involving 2 or more people were not consistently recorded in the records of all those involved and did not always reflect the impact or harm experienced. Fluid monitoring records contained inaccurate information, meaning the provider could not be assured people received sufficient hydration. Records did not consistently evidence where 2 staff members had supported people in line with their assessed needs. For example, 1 person required 2 staff members to support them to reposition. Their daily notes did not confirm whether 2 staff had provided this. In addition, care plans contained outdated information which did not always reflect people's current needs and circumstances.

These concerns demonstrated governance systems were ineffective in assessing, monitoring and improving the quality and safety of the service. The lack of accurate records and effective oversight placed people at increased risk of harm and prevented the provider from identifying and addressing concerns in a timely manner.

We gave feedback to the provider, who have taken action to rectify the concerns identified.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Healthcare professionals told us they shared information with the service to support people's health and wellbeing. However, due to ineffective oversight and under-reporting of accidents, incidents and events, the provider could not be assured all relevant information had been identified, recorded and shared appropriately with partner agencies. This limited assurance that all professionals involved in people's care were receiving complete information to support coordinated and person-centred care.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The service had an improvement plan in place. However, governance processes had not always been effective in ensuring actions identified through audits were incorporated into the plan, progressed, and monitored to completion. As a result, leaders could not be assured all identified improvements were being addressed in a timely and systematic way.

The registered manager had been in post for 2 weeks at the time of the inspection and had undertaken an initial review of the service. They had developed a revised improvement plan which reflected actions already undertaken, as well as the concerns identified during the inspection. The provider responded positively to feedback and had already commenced work to address identified shortfalls and strengthen oversight arrangements. This demonstrated a willingness to engage with the inspection process and take action to drive improvements in the quality and safety of care provided.