Aaron Court Care Home

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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The provider was in breach of the legal regulation in relation to safe care and treatment. Widespread concerns were identified regarding the cleanliness, hygiene, and safety of the environment. This increased the risk of poor infection prevention and control, cross-contamination, and physical harm. Unsafe practices, including incorrect equipment settings, lack of essential handwashing facilities, unsecured hazardous substances, and failures in medication and nutritional care, were found. Risk assessment and risk management were ineffective. The provider was in breach of the legal regulation in relation to staffing. Staff were recruited safely; however, there were systemic failings in how staff were deployed, supervised, trained, and supported across all areas of care provision. Domestic staffing levels were insufficient to maintain acceptable standards of cleanliness, contributing to infection control risks. We observed unprofessional behaviour, including loud verbal exchanges between staff in communal areas, indicating inadequate training and oversight. Staff were not receiving routine supervision, which contributed to a lack of support, unclear role expectations, and inconsistent standards of practice. Staff lacked clear guidance on how to support people safely. The registered manager had not taken appropriate steps to reduce the over-reliance on agency staff or to implement effective workforce planning to promote continuity and stability. Agency staff were regularly deployed without access to essential information about the service or the needs of the people using it.

This service scored 25 (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 or report safety events. Lessons were not learnt to continually identify and embed good practice. There was little evidence the provider promoted a culture of continuous learning and improvement. Accident and incident records lacked details about each event and there was no evidence to show events had been analysed to identify any themes, trends or ways to mitigate the risk of further occurrences. Some staff members told us they were not supported to reflect on incidents or near misses, and there were no formal processes in place for shared learning. Several members of staff told us when they raised concerns, these were not always documented or followed up by the registered manager. Opportunities to improve care from feedback, complaints, and safeguarding concerns were often missed or not acted upon in a timely manner. One person told us, “I don’t like to ask the staff for help.” Relatives shared concerns with us in relation to accidents and incidents. Comments from relatives included “Formal complaints have been made but they were verbal, and I had no response,” “I contacted the care home manager but as usual they never replied. I still have not had a response.” The provider was in breach of the legal regulation in relation to safe care and treatment.

The provider did not work well with people or other health and social care professionals to establish and maintain safe systems of care. People’s care was not always managed or monitored safely. The provider did not have safe or effective systems in place to ensure people's care was coordinated with other health and social care services such as the local authority and hospital. Partners agencies expressed concerns regarding the safety of people and the systems in place. Feedback from health and social care professionals was negative. They told us about concerns around continence care, pressure ulcer care, care plans not being reflective of needs, unexplained injuries, the lack of effective audit processes and managerial oversight, and delayed escalations to medical professionals. Staff lacked information and guidance to support people safely. Staff were not always aware of people’s current health conditions or treatment plans. Staff told us care plans were not always updated when people’s needs changed. One person told us, "They [staff] don't really know my needs." A relative told us they had to remind the provider about making a referral to external healthcare professional which resulted in a delay in the person receiving the support they needed. These findings evidenced a breach of the legal regulation in relation to safe care and treatment. The new interim home manager had identified the need for improvements and was working to establish better relations with partners to ensure smoother transitions and continuity of care.

The provider did not work well with people living in the home or healthcare partners to understand what being safe meant to them and how to achieve that. The processes in place to record, report and monitor safeguarding incidents were not accurate or effective. It was difficult to get a true picture of safeguarding incidents and whether appropriate action had been taken to prevent harm because records had not been maintained appropriately. For example, some of the safeguarding incidents reported to CQC were not on the provider’s safeguarding log and vice versa, which meant the systems in place to monitor safeguarding events were not accurate. The new interim home manager was submitting the required CQC notifications retrospectively. We found one person had sustained an injury from a recent fall, however, their falls assessment had not been updated for three months. Staff knew what action to take should they suspect or witness potential abuse. Staff reported they had received safeguarding training but told us they felt unsupported when it came to applying this knowledge in practice. One staff member stated, "Safeguarding has been brushed under the carpet" and another expressed worry about, "Finishing my shift and going home and coming back the next day to see possibly injured people.” Feedback from relatives regarding safeguarding was overwhelmingly negative. Comments from relatives included, “[Name] was left lying in their own urine with a pressure sore” and “[Name] does not have a call bell, and they have never had one since they moved in."

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People were not consistently supported to understand or take part in decisions about their safety and wellbeing. Care plans and risk assessments were often incomplete, outdated, or not reflective of peoples' current needs, leading to gaps in risk management. There were no clear strategies in place to ensure people were supported to understand and manage their own risks. Feedback from people highlighted concerns about the lack of personalised care and involvement in decisions regarding their safety. One staff member reported, "Relatives are not informed if their family member has had a fall." When we asked relatives if they and their loved one was involved in assessments, 2 relatives stated, “No not at all.” Other comments included “It is done without me knowing,” and “I have not been asked about anything to do with [Name.]” Relatives told us about failures to appropriately assess and respond to individual risks. Comments included, “[Name] needs help with feeding. I saw they were given an ordinary spoon. They tipped it all over themselves. No one came to help,” and “[Name] has a pressure sore, yet there has been no assessment for incontinence wear, and they have a pressure sore exposed.” Staff were not always aware of the current health needs or risks of the people in their care, which led to an inability to effectively support individuals in managing their own risks. These findings showed there was a breach of the legal regulation in relation to safe care and treatment.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. The premises were not consistently maintained to a high standard, and environmental risks were not adequately identified or managed. There were concerns about the physical safety of the building. We found unsecured hazardous substances in communal areas and people’s rooms. Trip hazards, such as loose wires were also observed in communal areas and people’s rooms. Some people’s pressure mattresses were placed on an incorrect setting which increased the risk of them being ineffective in preventing pressure sore development and discomfort. We observed broken radiator covers in some areas which increased the risk of people not being fully protected from the risk of a burn from a hot radiator. We brought this to the attention of the new interim home manager who had started to take measures to prevent people being exposed to environmental hazards. Feedback from relatives corroborated our assessment of the environment. Comments included, “I noticed a live plug socket away from wall, there were 2 screws missing. I reported it to the manager, but they did not respond to me,” “[Name]’s bed keeps breaking down,” “[Name]’s sensor mat does not work.” Emergency grab bags and information about people’s evacuation needs documented in personal emergency evacuation plans (PEEPs) were not up to date or accurate which raised concerns about the home's ability to keep people safe during an emergency such as a fire. A member of staff told us, "People are not even in the right rooms. PEEPs are incorrect. One person was not even on the right floor." This lack of management of environmental risks meant the provider was in legal breach of safe care and treatment. The provider assured us a plan was in place to improve the safety of the environment.

The provider did not ensure staffing levels were sufficient or staff were adequately trained and supported to provide safe and effective care. The workforce was often over-reliant on agency staff, who were not always provided with the necessary information or support to deliver high-quality care. Agency staff were placed on shifts without being given adequate handovers. We observed agency staff delivering care who could not identify who people were and did not demonstrate an understanding of people’s personal histories, preferences, or health conditions. We observed how this lack of familiarity and preparation created confusion and distress for two people. Staff did not receive regular supervision or opportunities for professional development, which contributed to a lack of support and guidance. Most staff told us they felt this lack of support and guidance affected their ability to respond effectively. On one occasion, we witnessed 4 members of staff verbally raising their voices and arguing with each other in front of people. We escalated this incident to the new interim home manager. Two members of staff told us this unprofessional behaviour was a regular occurrence. A relative also reported they had overheard a loud argument between staff members whilst they were visiting their loved one. We found medication errors and record keeping failures which further reflected inadequacies in staff’s competency and managerial oversight. Staff were not always deployed to meet people’s needs as we observed people’s verbal calls for support were not answered in a timely way, leaving people to wait for their personal care and not have their needs met. Relatives told us they did not think there were enough skilled staff on duty and felt the management of the staff was poor. Comments included, “There are some brilliant staff here, but some don’t seem to know what they’re doing,” “Staff are inexperienced and don't really provide any level of support,” “Staff are so busy they can't check on residents.”  This was a breach of the legal regulation in relation to safe care and treatment. The new interim home manager recognised there were shortfalls in staff competencies, training, supervision and deployment and was starting to take action to improve this.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. We observed widespread and serious breaches of infection prevention and control in respect of cleanliness, hygiene, and safety throughout the home. Multiple areas, including communal spaces, bathrooms, bedrooms, and laundry areas, were visibly dirty and poorly maintained. In several instances, bodily fluids and waste, and ingrained dirt were found in both shared and personal care environments. Staff were observed failing to follow safe IPC practices, such as correct disposal of personal protective equipment (PPE.) There was a lack of handwashing facilities for staff to use in critical areas, for example, the treatment room. There were not enough domestic staff to maintain hygiene standards, and some staff were unclear about their responsibilities around infection prevention. We found personal items such as unlabelled clothing and hairbrushes left in communal bathrooms, increasing the risk of cross-infection. Unsafe food storage and unclean fridges were observed. Jugs of water and juice in people’s room was often out of date. On two occasions we found jugs were 3 days old and had not been replaced. The lack of robust infection control systems meant people were placed at ongoing risk of preventable harm. Comments from relatives we spoke with included “The place is filthy,” “Rooms don't get cleaned regularly or effectively. I swept up and left the sweepings. They were left for 3 days,” "[Name]’s room isn’t cleaned. I have purposely left things there to see if it gets cleaned up. The family have to clean their room,” and “Pillows have not been changed for days. They are all marked.” This lack of effective infection prevention control meant the provider was in legal breach of safe care and treatment. The provider assured us a deep clean of the premises was scheduled to improve the cleanliness of the environment.

The provider did not make sure medicines and treatments were safe and met people’s needs. The provider did not have safe or effective systems in place to ensure the safe management and administration of medicines. Medicines were not always administered in line with current prescriptions. For example, a person continued to receive a medication for over 3 weeks after the GP had discontinued it, due to a delay in updating the medication administration record (MAR). We saw an instance where covert medication administration was undertaken without appropriate safeguards. This breached the person’s legal rights and highlighted a lack of oversight and proper governance. Care records and MARs were frequently inaccurate which increased the risk of medicine errors. There were omissions in allergy records. There was an absence of PRN protocols (A PRN protocol is a written plan that explains when and how to give someone medication only when they need it, not on a regular schedule.) Allergy information for several people was inconsistent or missing across documents which increased the risk of people being prescribed a medicine they were allergic too. Storage and stock control procedures were inadequate. A medication returns record had not been updated since 2024, and controlled drug (CD) checks were not completed as required. Staff we observed failed to reconcile controlled drugs, and did not rotate medication patches per guidance. Staff were unable to confirm medication allergies or apply appropriate risk mitigation, raising concerns about safe and competent practice. One relative told us, “There was some medication in a pot in [Name]’s room but it belonged to another resident,” “If [Name] is asleep, they don’t give their meds. I found it in the bin.". These findings showed a breach of the legal regulation in relation to safe care and treatment.