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 inadequate. At this assessment the rating has remained 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. The provider was in breach of the legal regulation in relation to governance and oversight at the service.

This service scored 36 (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 consistently demonstrate a shared vision, strategy and culture based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Leadership instability and limited involvement of people and relatives meant values and priorities were not consistently embedded across the service. Frequent changes in management made it difficult for staff, people and relatives to understand expectations, standards and direction. Most staff we spoke with told us they often felt unsure about expectations because managers changed frequently. Feedback about leadership visibility and approachability was mixed. Some people said they had limited opportunities to speak with leaders or were unsure who they were. Comments included, “No, I haven’t seen them” and “I’m not sure who they are.” Others reported their views were listened to. Some staff described one leader as approachable, fair and supportive, while others reported inconsistency in leadership presence and communication. People had limited opportunities to feel involved in how the service was run or to raise concerns directly with those in charge. Several relatives described frequent changes in managers and said contact with leaders often happened mainly when issues were identified through external scrutiny. One relative said, “I have never been introduced to any of the seven managers” and another said, “They only came out when they got the bad CQC report.” Leaders told us they aimed to create an open and supportive culture, including being visible and carrying out regular walkarounds. However, this was not consistently reflected in the experiences of staff, people and relatives.

The provider did not consistently demonstrate inclusive leadership at all levels or ensure that leadership was effective in embedding a positive, open and inclusive culture. Leadership was not consistently stable or visible, which limited trust, continuity and the provider’s ability to sustain improvement. Frequent changes in management made it difficult for staff, people and relatives to understand expectations, leadership approach and service direction. While leaders had relevant professional backgrounds and experience, this was not consistently reflected in effective leadership in practice. We identified gaps in oversight, responsiveness and the ability to recognise and act on risks. We were not assured leaders consistently responded appropriately to risk or were always receptive to feedback. This meant potential safety and safeguarding concerns were not always fully recognised or acted upon in a timely way. For example, when concerns were raised during assessments, the responses often explained the situation rather than showing clearly what was being done to manage the risks. Because of this, we could not always be confident that risks were being recognised and dealt with promptly. During the assessment, there were changes in leadership, including concerns identified about the conduct and effectiveness of the home manager. This further contributed to instability and impacted staff confidence and consistency of leadership. Feedback about leadership was mixed. Some staff described one individual leader as approachable, fair and supportive. Others reported inconsistency in leadership presence, communication and decision-making. Comments from relatives included, “Communication is terrible” and “You put in a written complaint, and you get nothing back.” Several relatives said leaders were more visible during periods of external scrutiny. When asked about leadership, some staff reflected the impact of frequent changes, with one saying, “It depends, we have had a lot of changes with different managers.” Leaders told us they wanted to be inclusive and approachable. One leader said, “We want staff to see us and not the badge with our job title.” However, this was not consistently reflected in the experiences of staff, people and relatives.

People did not always feel they could speak up, and their voice would be heard. Most relatives told us they did not always feel confident that raising concerns would lead to action or real change. Comments from staff included, “We are speaking to a brick wall,” and “I have reported concerns, but it falls on deaf ears.” Several relatives said they had to chase responses or take concerns outside the service to get attention. Some staff said they could not rely on a clear, safe and consistent way to speak up. Some staff we spoke with described being unsure who was in charge or who to go to. Leaders described having processes in place, such as meetings, surveys and whistleblowing policies.

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. Leadership instability, uneven communication and poor integration of agency staff limited the development of a genuinely inclusive and supportive workforce culture. Equality, diversity and inclusion were not clearly built into how the workforce was led or supported on a day-to-day basis. Frequent changes in managers created uncertainty and affected how included and supported many staff felt. Some staff spoke positively about specific leaders who they felt were approachable and fair. Leaders told us they wanted to build a more inclusive culture through staff meetings, surveys and recognition of staff efforts.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. The provider did not have strong or reliable systems to make sure risks were found early, dealt with properly and kept under control. Checks and audits were not working as they should. Some safety checks were recorded as completed, but in practice did not match these records. We found gaps and inconsistencies in people’s care records. Important clinical information such as long-term condition plans, bowel monitoring, thickener use and observations was missing or unclear. Medicines records were inconsistent and spread across different systems. Some relatives reported raising the same issues repeatedly, such as unexplained falls, missing equipment, lost belongings and poor communication, without seeing lasting improvement. Professional partners told us there had been a long period of instability due to frequent changes in management. Partners informed us the provider had not taken part in provider forums or focus groups for several months. Other professional partners told us training compliance was routinely monitored and reported through system-level oversight, and leadership and staff development frameworks were under review. We discussed our findings with leaders, who explained the systems they use to oversee quality such as reviewing complaints, checking incidents, working with medicines partners and improving oversight of care planning. However, these systems did not prevent the serious and repeated problems we found.

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. While some activities and connections were in place, there was limited evidence barriers to access, such as mobility, communication needs or cognitive impairment, were being identified and addressed in a structured way. Leaders described a range of community connections, including visits to local venues, church services, access to the library, activities with local schools and Duke of Edinburgh participants, and reminiscence sessions. Informal activities included a visiting horse. One professional partner described improved and more transparent engagement, with some leaders working collaboratively with commissioners and external agencies. Another partner confirmed frontline staff were able to answer questions about care plans and provide updates on people’s wellbeing. One professional partner described a “much better relationship” and improved communication and collaboration.

The provider did not consistently focus on continuous learning, innovation and improvement across the organisation and local system. Serious concerns identified at the previous assessment were still present, and actions taken had not been fully sustained or embedded. Systems for identifying risks, learning from incidents and making lasting improvements were inconsistent. People continued to be exposed to avoidable risk and recurring issues. While some risks and incidents were recorded, the same problems continued to occur, indicating that learning was not consistently translated into effective change. Most staff we spoke with told us frequent changes in management had led to inconsistency and confusion, which impacted the provider’s ability to embed improvement. Some relatives told us issues they raised were not always resolved, and several felt learning from incidents or complaints was not consistently effective. We observed leadership responses to feedback and challenge were variable. At times, leaders sought clarification or provided context in response to concerns raised. However, this was not consistently accompanied by clear evidence of reflection ,learning or sustained improvement in practice. Professional partners told us while some progress had been made, there remained areas requiring improvement. Leaders gave examples of actions taken following specific incidents. This included making changes after a situation where a person left the home and staff didn’t realise, they had gone. However, these actions were not consistently embedded across the service.