Aaron Court Care Home

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 good. At this assessment the rating changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.  We found the provider was in breach of the legal regulation in relation to good governance. Quality assurance systems and processes were not operated effectively, and there was a failure to identify and address areas requiring improvement. Managerial oversight of the service was lacking, and the registered manager failed to identify and share learning from accidents and incidents to prevent them happening again. This placed people at continued risk of avoidable harm. Staff told us they did not always feel able to speak up about the concerns they had about the service and when they did, they did not always feel their concerns were listened to and actioned.

This service scored 32 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. Our observations confirmed staff were task focused, and the culture of the service was not always positive for all people. People and staff were not involved in decision making, implementing systems or included in improving the service. This meant people received care that was provided by staff carrying out tasks which had not been organised or supervised to ensure safe care had always been provided. For example, people did not always receive food they preferred or required to maintain their safety and staff did not have all the information they needed to provide for people’s current needs. We saw staff team meetings had not been taking place regularly to encourage a positive work culture, for staff to raise views and suggestions on how to improve the service or to discuss their concerns. Staff morale was consistently described as low, with comments including, "Staff morale is low. I have never seen anything this bad in years,” and "Morale is low at the moment and probably due to uncertainty.” One staff member told us, “I have witnessed the manager scream at staff.” One staff member stated, "The staff just don't want to work. They want an easy ride" and another reported, "Staff go off shift and home whenever they feel like it with no consequences and leave the home unsafe numbered."

People did not always feel they could speak up and their voice would be heard. Comments from staff included, "When you raise concerns you get told off," "If we voiced an opinion we may as well have spoken to a wall" and "you get fobbed off." Some staff knew where to find the whistleblowing policy which outlined the procedure to follow up when speaking up about workplace concerns, whereas others did not. One staff member said, "Yes, we are given a booklet when joining the home which has the whistleblowing procedure inside" while another said, "No, I wouldn't know where it was.” Staff members told us when they had spoken up, action or a response from the registered manager had not always been received. One staff member told us, "I have often voiced to the manager the care team do not have adequate training to manage challenging behaviour and asked whether training could be provided for which I have never received a response.” Another staff member stated when they had voiced concerns to the registered manager, "Excuses are made when issues are raised. Communication is poor."

People did not always feel they could speak up and their voice would be heard. Comments from staff included, "When you raise concerns you get told off," "If we voiced an opinion we may as well have spoken to a wall" and "you get fobbed off." Some staff knew where to find the whistleblowing policy which outlined the procedure to follow up when speaking up about workplace concerns, whereas others did not. One staff member said, "Yes, we are given a booklet when joining the home which has the whistleblowing procedure inside" while another said, "No, I wouldn't know where it was.” Staff members told us when they had spoken up, action or a response from the registered manager had not always been received. One staff member told us, "I have often voiced to the manager the care team do not have adequate training to manage challenging behaviour and asked whether training could be provided for which I have never received a response.” Another staff member stated when they had voiced concerns to the registered manager, "Excuses are made when issues are raised. Communication is poor."

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had an equality and diversity policy in place, along with fair recruitment, induction and training for all staff. Cultural diversity within the staff team was positive, however, staff did not always feel they were treated fairly when they raised concerns. One staff member told us, “Some staff have voiced they are unable to attend appointments as the management would not cater it whereas other staff are able to leave the premises as and when to attend appointments.” There was no system in place for the management of staff well-being. One member of staff described a culture that was them [management] and us [staff].

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. We found little evidence of any effective audit systems in place to identify and address shortfalls in the service and in the safe delivery of people’s care. There was a lack of weight, nutrition and fluid management audits being undertaken which meant people at risk of malnutrition and/or dehydration were not having their food and liquid intake monitored. People’s risk assessments were not always reviewed following incidents to ensure they remained fit for purpose, and there was no clear strategy to prevent recurrence. For example, one person had sustained an injury from a recent fall, however, their falls assessment had not been updated for three months. Management oversight was inconsistent and inadequate which led to people experiencing poor quality care that did not meet their needs, wishes or preferences. Evidence based care was not provided and there was little evidence the provider had monitored the delivery of care appropriately to ensure it safely mitigated risks to people’s health and wellbeing. The registered manager lacked a clear understanding and commitment to ensuring their regulatory requirements were met which was a breach of the legal regulation of good governance. At the time of the assessment the provider had just implemented a senior management team to provide intensive support and oversight at the service. The new management team assured us an in-depth overhaul of the governance systems would be implemented as part of their support.

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. We found concerns about partnership working, both internally between teams and externally with other services and the wider community. For example, referral delays to other health and social care professionals, poor communication with staff and the registered manager about people’s needs, a lack of access to recreational activities to promote a positive care home community and a lack of collaborative working with partners were all reported and evidenced during the assessment.

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. They did not always actively contribute to safe, effective practice and research. There were no effective processes in place to identify and share learning across the service in respect of accident and incidents, best practice, and required improvements. Staff and management meetings did not take place regularly to promote learning, improvement and innovation. The registered manager was not proactive in ensuring evidence-based practice was embedded within service delivery. Staff reported feeling overwhelmed and unsupported in the workplace which hindered good staff practice and a blame free culture to reflect and continuously learn from their workplace experience.