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

This means we looked for evidence that people were protected from abuse and avoidable harm. During this inspection we considered how people were receiving services in line with Right Support, Right Care, Right Culture. At our last assessment in 2021, we rated this key question Requires Improvement. At this assessment the rating has changed to good. This meant people were safe and protected. The unit was safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well, however there had been an increase in restrictive practice due mainly to one patient.

This service scored 53 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Whilst the provider had an accident and incident reporting process, we identified gaps in records. Staff had not always completed or formally signed off records, to confirm all necessary actions had been taken.

We saw that an audit intended to identify themes and trends from accidents and incidents was overdue. Whilst some actions were taken and concerns discussed with relevant health professionals; records did not consistently evidence this. As a result, there was limited assurance that learning and improvement actions were consistently identified and embedded into practice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The current manager had been working with staff to make improvements to the information recorded within people’s care plans. This meant records and information required in an emergency, such as when a person went to hospital, contained more personalised information to share with partners.

Whilst there had not been any recent admissions to the service, feedback from care partners indicated improvements were in progress to support the continuity of care for people.

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. The provider did not always share concerns quickly and appropriately.

Staff did not always follow procedures designed to protect people from abuse. For example, one person had an unexplained skin tear, however, staff had not documented, assessed or reported this in line with the provider's procedures. We also found information related to bruising and skin tears, which had not been fully recorded to ensure any concerns were properly highlighted. This meant opportunities to consider safeguarding concerns and make appropriate referrals may be missed.

The home manager explained bruising or skin issues were usually discussed and considered with health partners, during their weekly meeting. However, they took immediate action to address the issues we identified and agreed to review records to ensure all injuries were consistently recorded and reported in line with safeguarding procedures.

The service needed to improve the timely reporting of low-level concerns. Monthly reporting, required by the local authority, had fallen behind in the previous 2 months.

Staff received safeguarding training and told us they felt assured if they raised any concerns managers would take them seriously.

The provider did not always work effectively with people to understand and manage risks. Staff did not consistently provide care that was safe, supportive and enabled people to do the things that mattered to them.

Whilst improvements were being made, further work was needed to ensure staff consistently implemented and effectively monitored risk management plans. For example, some people had sensor mats in their bedrooms to alert staff to movement and enable a prompt response to support their safety. However, 2 mats were not functioning, and timely action had not been taken to deal with these, we also identified a further mat which was not working. The home manager took immediate action to address the concerns identified.

Staff had undertaken various environmental risk assessments, however in some cases these were not relevant or had not been recorded. For example, in relation to the safe storage of toiletries in people's bedrooms, which was particularly relevant for people living with dementia, who may be at increased risk of unintentionally misusing or ingesting such items.

However, in other areas staff were taking actions to assess and manage identified risks. Care plans included guidance for staff on the support people required.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We identified ongoing concerns regarding the provider's oversight of maintenance checks and their systems for managing maintenance and environmental works. There were gaps in maintenance records, and we could not be assured all required actions had been completed or addressed in a timely way. For example, a previous fire risk assessment had identified several actions. Whilst these had all been signed off, we observed an action being carried out during our site visit, indicating a significant delay in completion.

Communication between the provider's head office and the home's management team was not always effective. The manager was unable to confirm the status and progress of all required works, which meant we could not be assured all actions were being completed promptly. The provider took some immediate actions in relation to this.

The provider was in the process of completing re-refurbishment works and re-decoration at the service. New furniture and flooring had been supplied in some areas. They had an extensive environmental action plan, with ongoing work in progress.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people's individual needs.

There were enough staff deployed to meet people's needs. There was a consistent staff team, with one current vacancy. People and their relatives spoke positively about staffing arrangements. One relative told us, "The staff are fantastic. There is a regular team, and you get to know them."

The manager told us they had focused on developing positive and supportive working relationships with staff. Regular supervision meetings had recently been introduced, with a schedule in place to ensure these took place regularly. Annual staff appraisals were also planned.

Improvements had been made to staff training compliance, with an increase in staff completing their required training. The provider had employed a dementia specialist lead, to support good practice and develop additional training for staff.

Overall, the provider followed safe recruitment procedures. However, in one recruitment file reviewed, gaps in employment history had not been fully recorded. These were clarified during our assessment.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The environment was generally clean, with domestic staff undertaking cleaning duties throughout our visits, although some equipment needed more robust cleaning.

Staff had access to PPE however, we observed some inconsistent infection prevention and control practices, including an example where staff did not use PPE where required. The manager acknowledged our observations and confirmed that additional monitoring of PPE use would be undertaken.

The provider was also working with the local Infection Prevention and Control (IPC) team to support ongoing improvements, alongside the continued refurbishment of the home.

The provider was making improvements to make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.Medicines were stored securely and areas used to store medicines had the temperature monitored. Staff had received training around medicines and had their competency assessed. When staff had found temperatures had gone beyond the recommended ranges actions had been documented.

For people who had thickener powder added to their drinks to reduce the risk of choking, we found records did not always give assurance that the right level of thickener had been added. Further work was needed in this area to ensure safe management and record keeping.

Systems showed that medicines prescribed to be given at specific times for Parkinson’s disease were administered as prescribed. However, we found that medicines containing paracetamol that require a 4-hour gap between doses were sometimes given too early. This had been picked up by staff during medication audits and actions had been taken

For individuals at risk from the recent heatwave due to prescribed medicines they were taking such as antipsychotics, care plans had been completed to ensure that staff had the information they needed to look after people safely, however we did see that some care plans and PRN protocols did not always contain person-centred information and some care plans had out of date information in them.

For one person who previously had their medicines covertly, due to refusing them. Staff had supported changes to the formulation of their medicines, which meant they now accepted their medicines, and they no longer needed to have these administered covertly.

Topical medicines such as creams were recorded when administered and when these medicines posed a risk due to being flammable there was completed risk assessments.

We saw that for medicines that are administered via a patch, staff kept a record of where the patch had been applied and documented daily checks to ensure that the patch remained in place.