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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm. The provider was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed safely.

This service scored 38 (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 always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Many staff told us the learning culture had weakened due to frequent changes in management. Leaders acknowledged learning systems were not fully established. Daily meetings were not always effective, and responsibilities for care plans were unclear. Some staff reported early improvements following the most recent management change. One staff member said, “We did go through a sticky patch, but it has improved this week.” Several staff members described reflecting more on their practice and said knowing people well helped them manage situations safely. One staff member said, “The best thing is knowing the residents well, because it can calm situations down.” Some professional partners told us a learning culture was beginning to develop, supported by regular multi-agency meetings to review actions and share lessons. Leaders said they had a quality programme involving audits, oversight and incident reviews, including learning from issues such as pressure sores. They described improvements made after a recent incident where a person left the building unnoticed, such as enhanced door security and a system to locate people quickly.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. We found most people’s care plans could not always be relied on to guide the delivery of safe care. There was missing and conflicting information within care records. For example, some people who were at high risk of falling did not always have clear plans to prevent further falls. Some professional partners raised concerns regarding inconsistency and described a disparity between what leaders said should happen and what happened in practice. One professional partner told us some frontline staff could not see important updates because information was only sent to managers. Another professional partner said the provider is generally responsive when it comes to referrals, admissions, or discharge; however, there have been some delays in re-banding of needs from residential to nursing care. We shared our findings with leaders who told us they were working to improve systems, including better electronic records, sharing professional advice, using hospital passports and adding risk monitoring tools.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Although systems for reporting concerns had improved, people were not always protected from abuse due to ineffective oversight. We found safeguarding records did not always show what action had been taken after concerns were raised, which made it difficult to determine whether concerns had been properly followed up. Relatives raised concerns about repeated unexplained injuries and falls, with little follow-up or communication. They said the lack of information left them uncertain about their loved one’s safety. Most staff we spoke with showed a good understanding of how to report abuse or poor care. One professional partner said staff had become more confident in identifying and escalating concerns and seeking advice when unsure. We shared our findings with leaders, who described actions they were taking to improve safeguarding oversight. However, these actions should have been implemented following the last assessment.

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. Restrictive practices were used without clear involvement, consent or review, and records did not support safe, lawful decision making. We observed people subject to restrictions that limited freedom of movement, for example, being blocked in by tables or repeatedly told to sit down without evidence of explanation or appropriate risk assessment. Where restrictions were used such as sensor mats, locked doors, removal of call bells, and increased supervision, records did not show whether people were asked for consent, whether their ability to make decisions had been assessed for that situation, or whether less restrictive options had been considered first. Care plans and reviews did not reliably show how people were involved in risk decisions, or whether restrictions were necessary, time limited and regularly reviewed. Several relatives told us they had raised safety concerns repeatedly without seeing changes. Some staff said workload pressures made it hard to involve people meaningfully in managing risk. Leaders told us they were improving how decisions about risk were recorded and were piloting new technology to help reduce the risk of falls. They did not give a timescale for implementing these changes.

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 building and equipment were not always safely maintained, leaving people exposed to avoidable harm. Dangerous areas were left unlocked, including sluice rooms, boiler rooms, storage sheds and staff-only areas, meaning people could have accessed hazardous environments. Unsafe items such as tools, blades, paint, wood stain and cigarettes were easy to reach. There were numerous hazards across bedrooms, bathrooms and communal areas, such as exposed wiring, damaged fixtures and unstable furniture. These posed daily risks to people. We found access to a fire extinguisher was blocked, and a communal fire door was obstructed by tables. This formed part of a wider pattern of environmental risks identified during the assessment. We repeatedly found urine on the floor in shared corridors, including on one household where this was associated with a known behavioural need. Staff were aware of this risk, however, this was not consistently managed in a way that prevented risks to others. Personal Emergency Evacuation Plans (PEEPs) were not reliable, with some containing missing or inconsistent information. This meant staff would not have clear guidance to evacuate people safely in an emergency. We observed unsafe moving and handling practices, including slings being put on incorrectly, staff pulling on slings instead of using safer techniques, and wheelchairs not being properly braked during hoisting. Some staff we spoke with raised concerns about safety equipment such as call bells not working or being switched off. Some relatives described hazards in the environment, including broken heating controls and a lack of supervision. One relative told us they saw a person try to clean their teeth with a knife and then a fork.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. We observed unsafe moving and handling practices, including slings being put on incorrectly, staff pulling on slings instead of using safer techniques, and wheelchairs not being properly braked during hoisting. We intervened to protect people. Some said the right mix of skills was not always in place. Some relatives described “lots of changes,” and “lots of strange faces.” Several relatives said their loved ones struggled with unfamiliar staff and staff appeared rushed or understaffed. Others said they regularly saw familiar staff and felt there were enough staff around. Most staff understood how involving people in their care can improve safety and dignity. Staff behaviour and professionalism had improved since the last assessment. One professional partner reported improvements in staff knowledge and competence, saying staff were better organised and more effective in supporting care delivery. We found improved recruitment processes, including background checks, training and structured induction for new staff. Leaders said agency staff were being encouraged to move into permanent roles to improve continuity. 

The provider did not consistently assess or effectively manage the risk of infection. They did not consistently detect and control the risk of it spreading. Systems to prevent the spread of infection were not working reliably. We observed several unclean areas in the environment, unsafe infection prevention and control (IPC) practices by staff and ineffective waste and laundry practices which did not consistently prevent the risk of cross-contamination. Several bedrooms and bathrooms were contaminated with bodily fluids, along with strong odours. Some areas and equipment could not be properly cleaned because they were damaged, including a shower head holder, shower drain cover, rusted bathing equipment and broken seals. We found soiled bedding and visibly dirty surfaces. We found empty, broken or missing soap dispensers and a lack of paper towels. We observed some staff handling food or bodily fluids without using appropriate personal protective equipment or washing their hands. Clinical waste was not always disposed of appropriately, with some waste placed in general bins. Some bins were broken or missing pedals. Laundry practices did not consistently prevent the risk of cross-contamination. Food was not consistently labelled with key information such as opening dates, preparation dates or use-by guidance, which meant we could not be assured food was being stored and used safely. We continued to identify infection prevention and control concerns across multiple days of the assessment, indicating improvements were not embedded or sustained in practice. Leaders acknowledged some of these issues were present prior to the assessment. While actions had been identified, we found risks were not consistently addressed or resolved in practice at the time of assessment. Several relatives said cleanliness appeared to improve when inspectors were present or following external scrutiny.

The provider did not consistently ensure medicines and treatments were safe or met people’s needs, capacities and preferences. People were not always involved in planning their care. Medicines systems were not working safely or reliably. People did not always receive their medicines as prescribed. We found several occasions where people did not receive their prescribed medicines. In some cases, people missed several days of medicines intended to prevent or treat health conditions, including medicines for stomach protection, infections, vitamin supplementation and blood‑thinning. Missing these medicines increased the risk of complications, such as infection worsening or the development of blood clots. These issues showed medicines were not always available when required. Medicines were not always stored safely. Fridge temperatures were recorded outside safe ranges without appropriate action being taken. Controlled drug checks were incomplete. We found stock discrepancies, including missing antipsychotic medication, which had not been clearly investigated. We observed an unlocked medicines trolley left unattended. When this was raised, leaders did not demonstrate a clear and consistent understanding of the level of risk presented. Thickening agents used to make drinks safer for people with swallowing difficulties were not always stored securely. The use of thickener was not consistently recorded, and we could not be assured drinks were always prepared safely. Records for skin patches were incomplete, and we identified discrepancies between prescribed medicines and records of administration. Some people were given medicines hidden in food or crushed without clear evidence of appropriate authorisation. The provider’s audits and recent external checks had not identified the range or severity of the medicines-related concerns we found.