Aaron Grange 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question good. At this inspection this has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 61 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff consistently described the home as a “nice culture” and said they enjoyed working there, with multiple staff commenting on positive teamwork and feeling appreciated. We saw evidence that leaders promoted an open and collaborative culture. People and staff told us they felt the home was improving, and staff described that it felt like a “safe space” where everyone “mucked in” to support each other.

Staff understood the provider’s expectations, and there was evidence of learning from incidents, including adjustments to practice following trends identified through internal reviews.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were visible, approachable and described by staff as supportive and fair. Staff repeatedly referenced the deputy manager as “very good”, “fair” and “doing the best she can” and told us that senior managers were present and checked in with teams. Staff said they felt supported, valued and able to bring new ideas. Leaders demonstrated good knowledge of the service and were honest about areas still needing improvement. The provider and deputy manager acknowledged where work was required, particularly around the consistency of care records, and had already started to address this at the point of inspection, however this still required further work to become embedded.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt comfortable raising concerns and would feel safe to whistle blow if needed. Comments included “I would feel comfy raising a concern” and “I feel comfy speaking up”. Staff told us they trusted the deputy manager and felt listened to, and there were clear whistleblowing and safeguarding policies in place that aligned with national guidance.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt valued, included and respected. The service supported a diverse workforce, and staff said the culture was positive, fair and inclusive. Training compliance included equality and diversity topics, and there was no evidence that staff felt disadvantaged or unsupported. Staff feedback indicated that teams worked well together regardless of role, background or experience, and the organisation’s policies supported equality, reasonable adjustments and inclusive practice.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes.

Governance systems were in place and an audit had identified some areas which needed improvement, such as MCA assessments, environment, supervision and some care records. However, the audit did not pick up or address some of the concerns we found during our inspection in relation to specific people’s risks in the care planning. Some care records lacked consistency, clarity and person-centred detail, and in many cases risk assessments and care plans were overdue, contradictory or missing essential information.

Analysis of incidents and accidents lacked effectiveness, as repeated patterns in falls were not consistently identified, limiting learning and preventing sustained improvement. This meant governance was not ensuring accountability, safety or sustainability at the time of inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with

The home was involved in its local community, and leaders told us they were committed to developing this further.

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.

The provider did not always learn effectively from incidents and audits. Although leaders carried out detailed analysis, similar risks recurred across the year. This included falls during predictable periods, gaps in care planning and inaccurate weight recording. Some learning had occurred, such as improved identification of early skin damage following training, but this was not consistently embedded.

Staff told us the culture was improving and leaders were receptive to feedback. However, governance weaknesses and repeated patterns in incident themes showed that learning was not always translating into sustained improvement. Further work was required to ensure lessons learned resulted in measurable, long-term change.