Aaron Grange 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 that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of regulation in relation to the management of risks.

This service scored 62 (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 had a learning culture, but this needed further improvement before it was embedded.

Staff and leaders reviewed incidents, but repeated themes, for example, falls during busy periods or in low visibility areas, continued over time. This showed learning was not consistently leading to improvement. Records showed actions were identified but not sustained, with missed opportunities for early intervention, including overdue risk assessment reviews and gaps in observation records. Staff told us they felt supported and able to raise concerns, and we saw examples of reflective practice. Sustained improvement was hindered by inconsistent documentation and gaps in supervision, which limited opportunities to maintain competency and embed lessons learnt.

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.

Staff ensured individuals had access to GPs, district nurses, specialist teams and urgent reviews when required. There was some evidence of actions being taken following incidents, including changes to support plans and clinical oversight. However, some records lacked the detail needed to guide staff, particularly around diabetes, catheter care and wound management. This posed a risk during handovers or when new staff were involved. Despite this, pathways for escalation were clear, and staff could describe what they would do if people’s needs changed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff understood their responsibility to protect people from abuse and avoidable harm. Safeguarding concerns were reported promptly, and information was shared with external partners. Staff demonstrated knowledge of different types of abuse and how to report them. Overall, people told us they felt safe living in the home. Deprivation of Liberty Safeguards (DoLS) were appropriately applied for.

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 always involved in understanding or managing risks relating to their care.

Important information such as diabetes plans, falls mitigation, catheter care instructions or nutrition requirements was missing or inconsistent. For 1 person, the falls care plan recorded “not a falls risk” despite their risk assessment scoring them as high risk, and there was no explanation of mitigation measures in place to keep the person safe. Their mobility plan stated only “closely observe”, without any detail about how staff should do this, when, or what signs to monitor, meaning new or temporary staff would not have the information needed to support them safely.

Several people with diabetes did not have a diabetes care plan in place, and where plans did exist they lacked detail about required blood sugar ranges, actions needed if readings were high or low, and whether monitoring was still required. In 1 example, the staff had stopped taking blood sugar levels without clear recorded clinical instruction, and there was no documentation explaining how staff should identify or respond to deterioration linked to diabetes.

These omissions showed the provider had not taken all reasonable steps to ensure risks were properly assessed, documented and managed, placing people at risk of avoidable harm.

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

The environment was generally clean and calm, and we saw staff taking action to address hazards following incidents. However, several checks lacked full dates or clear identification of which items had been inspected, which reduced the provider’s ability to ensure environmental safety.

Some equipment, such as sensor mats, required repair, and documentation did not always show whether actions had been completed. Staff and people told us some areas of the building needed modernisation, and outdoor spaces required improvement. The provider had an environmental plan in place, which had identified these actions but they had yet to take place.

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.

For example, almost 70% of staff had not received a recorded supervision in the last 12 months, limiting oversight of competency, wellbeing and reflective learning. Training compliance was below the provider’s target, and gaps in care planning highlighted inconsistencies in applying training to practice. We raised this on day 1 of our inspection and the provider was able to evidence this was something they were working towards as it had been identified by their own audit systems. They had already begun to address the training gaps, and when we returned for day 2, we saw the percentage of staff training had increased.

While staff felt there were enough colleagues on most days, patterns of falls during busy periods and reduced visibility suggested skill mix and deployment required review.

Recruitment followed safe processes.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed effective hand hygiene, appropriate personal protective equipment (PPE) use and clean clinical areas. Handwashing instructions and sanitiser were available throughout the home. Staff were bare below the elbows and changed PPE between rooms, and the environment was visibly clean.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

MAR charts were completed accurately, with photos, allergies and clear instructions included. Controlled drugs were stored securely, and records were up to date. No missed doses were identified, and room and fridge temperatures were recorded daily.