Aaron Court Care Home

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 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 inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes. We found the provider was in breach of the legal regulation in relation to the need for consent. We identified concerns regarding the provider’s compliance with the Mental Capacity Act 2005 which protect people’s legal right to consent to their care. Staff were not always following best practice guidance when assessing people’s capacity and were placing restrictions on people, which were not appropriate.  We observed instances where restraint was used without appropriate legal safeguards, documentation, or justification. Some people were routinely confined to bed without evidence of consent, formal capacity assessments, or supporting risk assessments to justify these decisions.

This service scored 29 (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. The provider did not consistently demonstrate a robust or timely approach to assessing and reviewing people’s needs. While some staff reported risk assessments and care plans were updated, others raised concerns about delays in updating people’s care plans when their needs changed. One staff member stated, “They aren’t updated quickly enough. We are not responsive when needs change.”. Another staff member told us, “I have returned from leave and a service user has been admitted. However, there were no risk assessments available.”. Some care staff expressed they did not always have time to read care plans. This was also reflected in relative’s feedback. One relative told us, “I don’t feel they’re always aware of [Name]’s changing needs. I have to keep repeating myself." One person told us, "The staff here don’t really know my needs.” The care plans reviewed during our assessment lacked important information about people’s personal life histories and preferences. Inaccuracies and omissions were found in essential care documentation. For instance, a care plan for one person failed to include whether their wound had healed. We saw one person’s skin integrity care plan lacked essential instructions for barrier cream use. This lack of accurate assessment and management of people’s needs meant the provider was in legal breach of safe care and treatment.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards. As a result, care and treatment was not always delivered in a way that met people’s needs. Malnutrition Universal Screening Tool (MUST) scores, weight charts, and fluid intake records were inconsistent, inaccurate, or implausible, undermining the reliability of monitoring of risk. This aligned with concerns reported to us from relatives about ‘worrying weight loss’ and staff reports of taking photos of inadequate meal portions to show to management. Clinical assessments showed significant gaps. For example, we found no evidence of appropriate care planning for specific medical needs, like pressure care and diabetes. In one instance we saw a person’s care plan was inaccurate, lacking updates on equipment usage, repositioning schedules, and catheter care. Wound assessment was particularly problematic. For example, one person’s wound care documentation was incomplete and inconsistent. This was a legal breach of safe care and treatment.

The provider did not always support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support. Positive individual efforts were observed, including a staff member who encouraged independence and dignity during mealtimes, and a relative praised a specific staff members kindness, “They really take time with [Name]. It makes a big difference.” We observed some staff members encouraged independence and dignity, such as involving people in craft activities. However, these isolated instances were not representative of the overall environment. Observations during mealtimes identified people had limited food choices. The dining experience was rushed, impersonal, and staff did not engage with people in a meaningful way. For example, people were served only egg and chips, and those who voiced to staff they disliked eggs were left with just chips. This resulted in some people feeling hungry. One person told us, “I’m still hungry after meals. It’s just not enough.” A staff member reported to us meals were often small, with no opportunity for seconds, and snacks were not provided regularly. Relatives, and other professionals alerted us to concerns about weight loss. We found several people were spending all day in bed without proper justification or documentation. There was no evidence remaining in bed was people’s preference. Some parts of the home were uncomfortably cold. Some people told us they were feeling very cold in their rooms. Other areas of the home were uncomfortably warm, and people were complaining they were too hot. People were observed sitting in silence for extended periods with no interaction or stimulation. One person told us, "I am just left in my room all the time. I am bored." Relatives told us, "It worries me [Name] is sitting in a chair all day not doing very much" and "I feel when I visit the residents have very little in the way of stimulation other than the television." One member of staff told us, “I would not recommend Aaron Court as there is a lack of activities available for residents and there are not enough staff members to meet the needs of the residents beyond basic care."

The provider did not always support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support. Positive individual efforts were observed, including a staff member who encouraged independence and dignity during mealtimes, and a relative praised a specific staff members kindness, “They really take time with [Name]. It makes a big difference.” We observed some staff members encouraged independence and dignity, such as involving people in craft activities. However, these isolated instances were not representative of the overall environment. Observations during mealtimes identified people had limited food choices. The dining experience was rushed, impersonal, and staff did not engage with people in a meaningful way. For example, people were served only egg and chips, and those who voiced to staff they disliked eggs were left with just chips. This resulted in some people feeling hungry. One person told us, “I’m still hungry after meals. It’s just not enough.” A staff member reported to us meals were often small, with no opportunity for seconds, and snacks were not provided regularly. Relatives, and other professionals alerted us to concerns about weight loss. We found several people were spending all day in bed without proper justification or documentation. There was no evidence remaining in bed was people’s preference. Some parts of the home were uncomfortably cold. Some people told us they were feeling very cold in their rooms. Other areas of the home were uncomfortably warm, and people were complaining they were too hot. People were observed sitting in silence for extended periods with no interaction or stimulation. One person told us, "I am just left in my room all the time. I am bored." Relatives told us, "It worries me [Name] is sitting in a chair all day not doing very much" and "I feel when I visit the residents have very little in the way of stimulation other than the television." One member of staff told us, “I would not recommend Aaron Court as there is a lack of activities available for residents and there are not enough staff members to meet the needs of the residents beyond basic care."

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure outcomes were positive and consistent, or met both clinical expectations and the expectations of people themselves. Care documentation showed gaps in outcome monitoring which made it difficult for us to track people’s care needs. For example, one person had a documented history of a pressure wound, yet their care plans for skin integrity, pressure area management, and wound care, did not clearly state whether this wound had fully healed or was still being treated. We found wound assessment was not being adequately or regularly undertaken with photos and measurements to show healing. For example, we were concerned about the lack of detail in one person’s wound monitoring chart, care plan and daily notes, and asked for assurances the wound was healing as there was a lack of documented checks being undertaken in relation to the wound. We found there was frequently gaps in documentation showing people had not been repositioned often enough. For example, one person was being repositioned every 4 hours when their care plan stated they need to be repositioned every 2 hours. The provider told us people’s weights were being monitored but had not been routinely audited by the registered manager. We found inconsistencies and implausible figures being submitted onto people’s weight management charts. For example, one person’s weight monitoring chart stated they had lost 30kg in one week. No documented action was taken following the recording. Weight loss was a theme of concern from relatives we spoke with. Professional partners we spoke with voiced concerns people were not being referred to other professionals when needed in a timely manner to get them the most appropriate support.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment. There was not a consistent understanding among staff of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). While some staff demonstrated a sound understanding, saying, “Every person must be assumed to have capacity until a formal assessment has been completed,” others were unclear or unable to explain the legislation. One member of staff simply said, “I don't know,” when asked about DoLS. Staff were observed applying restrictive practices without lawful justification. For instance, one person was walking with purpose and appeared content when they were repeatedly physically redirected to sit in a chair. There were no supporting assessments, consent forms, or best interest decisions in their care records to justify this practice. Multiple people were routinely kept in bed throughout the day and night with no recorded rationale or any indication this was people’s own choice. Two members of staff and multiple relatives told us they had raised these concerns with the registered manager, but no action was taken. One person’s Deprivation of Liberty Safeguards (DoLS) authorisation had expired in December 2024, meaning they were at risk of being deprived of liberty unlawfully. We found covert medication was administered without proper consent processes. One person’s care record stated they were receiving medication covertly (hidden in food or drink). However, the DoLS authorisation did not reference the covert administration of medication. There was no documented evidence of a best interests meeting, consultation with the GP, or involvement of the pharmacy regarding this approach. Additionally, the person’s care plan stated they preferred to self-administer their medication, raising concerns about whether their capacity and preferences had been adequately assessed or respected. These shortfalls in understanding and protecting people’s right to consent to their own care and treatment was a legal breach of the regulation in relation to the need for consent.