Aston Manor EMI Residential Home

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Inadequate.This meant there were widespread and significant shortfalls in people’s care, support and outcomes.The service was in breach of legal regulation in relation to people’s safe care and treatment.

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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them. We found that effective systems were not in place to assess, monitor and mitigate risks to people. We identified some people’s needs were not met in respect of management of their skin integrity, mobility and nutrition and hydration. This put people at risk of being harmed and their health and wellbeing deteriorating. We observed a lack of assessment of people’s needs and risks to them. Care plans were not always detailed with a lack of information to reflect changes in people’s needs such as people’s mobility or specific health conditions resulting in gaps in the information available to staff. The lack of guidance for staff in care records placed people at risk of harm or injury.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. During our assessment we reviewed care plans which lacked person-centred detail and did not include what was important to them. The provider had used tools such as MUST score (nutritional risk assessment) and the Waterlow tool (pressure ulcer risk assessment), however these were not then reviewed or updated for people, therefore not always effective at managing risk. We found the provider failed to manage risks associated with service users’ nutrition. The system in place to monitor service users’ weight had not been effective in ensuring timely action was taken in relation to service users at risk of losing weight or continuing to lose weight. Relatives we spoke with told us they were not involved in people’s care plan.

The provider did not always work well across teams and services to support people. We found known risks to people’s care and health were not well managed. This placed people at risk of receiving unsafe care. Inspectors observed staff using unsafe moving and handling practices while supporting a person to mobilise. Inspectors spoke with staff who said they were having difficulties supporting the person with their mobility and a referral to the occupational therapy service had been made on 18 June 2025 to request support. Inspectors spoke to the registered manager about this referral, and they advised the referral had been sent to the wrong service and contact had been made to the correct service on the 23 June 2025, the same day as our assessment.

The provider did not support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support. We found the provider failed to manage risks associated with service users’ nutrition. The system in place to monitor service users’ weight had not been effective in ensuring timely action would be taken in relation to those at risk of losing weight or continuing to lose weight. People with weight loss did not have a care plan or risk assessment in place detailing how to reduce risks associated with weight loss such as fortified meals or the provision of regular snacks. People with recent weight loss, did not always have their food and fluid recorded or monitored.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. The registered manager told us they routinely monitored people’s care and treatment. However, we found risks to people’s skin integrity were not always managed well. Some people were at risk of developing issues with their skin integrity. We found regular repositioning was not always taking place and people’s care plans did not provide appropriate guidance to staff to provide safe care in this area. People assessed as being at a severe risk of developing pressure ulcers had limited information within their skin integrity care plans about the action staff should take to reduce the risk. The National Institute for Health and Care Excellence guidance on Pressure ulcers states people at very high risk of developing pressure ulcers should be repositioned every 2 hours to prevent damage to skin integrity. Inspectors found not everyone had repositioning charts in place and not all required information within care records to instruct staff on how often repositioning should take place. Staff told us some people were not being repositioned at all if no chart was in place, other people who had a chart for repositioning staff were not always documenting that repositioning was taking place as frequently as required.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment. The service had applied for Deprivation of Liberty Safeguards (DoLS) when required to do so. However, some restrictions with equipment in place for people who lacked capacity did not always have required mental capacity assessments in place, to ensure the implementation of the restrictions was in line with legislation.