Aria Court

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 assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had systems in place to record, monitor and review incidents using an electronic system. Staff told us incidents were analysed monthly and discussed in clinical governance meetings.

Leaders described monthly clinical meetings where incidents, including falls and infections, were reviewed and lessons learnt were discussed. For example, following an increase in chest infections, the service introduced additional oral care learning and training for staff.

Staff told us learning was shared through team meetings and bite-size training sessions.

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 service had established processes for pre-admission assessment, which were completed through both local authority referral pathways and internal clinical assessments.

The provider described a structured initial assessment process led by a senior member of staff and a clinical lead. This was used to determine whether the service was able to safely meet a person’s needs prior to admission and to support safe transition into the service.

In some cases, people were supported to visit the service in advance as part of a planned assessment or “taster” visit to help inform decision-making and support familiarity with the environment before admission was agreed.

A professional involved in care planning stated that the service engaged appropriately with external agencies during periods of transition and reviewed care arrangements when people’s needs changed.

Systems were in place to support admission, transition and re-assessment processes, with input from internal and external professionals where required.

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 demonstrated a clear understanding of how to recognise potential abuse and neglect. They were able to explain how concerns would be identified, recorded and escalated, and who they would report to within the service and externally where appropriate.

Staff spoke confidently about the safeguarding process and gave examples of how they would escalate concerns in practice. One staff member told us, “When I am concerned or unsure if something is safe or not, I will report it anyway and investigate just to ensure the residents are safe and well supported. I will speak up no matter what.”

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

A small number of documentation issues were identified relating to wound care monitoring. In one example, records lacked clarity about monitoring frequency. Staff confirmed there was no active wound dressing and that this related to monitoring only. The provider acknowledged system wording limitations and confirmed these had already been identified as part of a planned review of the digital care planning system.

Despite this, risk management was understood by staff and systems were in place to support safe practice, with identified documentation issues already recognised and being addressed through planned system improvements.

Risk assessments and care plans covered areas such as mobility, clinical needs and ongoing monitoring. People and families were involved in care planning where appropriate, and staff demonstrated awareness of individual needs when managing risk.

Learning from feedback was evident in practice. For example, following a concern raised by a person about the use of mobility equipment, staff reviewed practice and reinforced guidance to ensure equipment used was appropriate and in line with assessed need.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was clean, safe and well maintained. Routine health and safety checks, fire safety systems and equipment servicing were in place and up to date.

A barcode reporting system enabled staff, visitors and families to report environmental concerns directly to maintenance teams. One minor fire‑door issue identified during the inspection was addressed promptly.

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.

The service used a dependency-based staffing model across 4 communities to determine staffing levels in line with people’s assessed needs. Staffing included care staff, registered nurses, clinical leads, housekeeping staff and activity staff, supporting delivery of care across the service.

There was a structured recruitment and onboarding process in place.

New staff received a structured induction programme. Practical induction sessions were completed in person across provider services.

Staff completed e-learning prior to undertaking shadow shifts. Once mandatory online training was completed, staff were allocated shadow shifts and supported by a designated buddy staff member. This ensured new staff were supported during early practice and able to apply learning in a supervised setting.

The provider had introduced a “Getting to know me” approach to probation review periods. This replaced a more formal probation model with a structured but supportive review process designed to encourage reflection, participation and ongoing development during the early employment period.

Training records showed that mandatory training was up to date.

Relatives who had previously raised concerns regarding staffing during busy periods told us they had seen improvements in the consistency and availability of staff.

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.

The service was observed to be clean and well maintained overall. Cleaning schedules were in place and followed, with clear systems for recording completed tasks.

Infection prevention and control audits were in place and actions identified from these audits had been completed, demonstrating ongoing monitoring and follow-through.

Equipment cleaning was carried out by night staff, with processes in place to ensure items were cleaned, checked and appropriately labelled.

Laundry and waste systems were organised and appropriately managed by a designated housekeeping team.

During the inspection, we observed visible hand hygiene prompts displayed across key areas of the service, including handwashing signage to support staff practice.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People usually received their medicines safely and in line with the prescribers’ instructions. Medicines administration was recorded using an electronic medicines administration record (eMAR) system, which included prompts and safeguards to support safer administration and record keeping. Staff described a structured process for medicines reconciliation on admission, including checking medicines against hospital discharge information and the general practitioner (GP) medicines list, with a second staff check before medicines were added to eMAR. Staff used “do not disturb” tabards during medicines rounds to reduce interruptions. As required (PRN) medicines protocols were in place and staff consistently recorded the reason for administration and whether the medicine had been effective, which supported review of symptoms and outcomes. Medicines were stored securely in locked clinical rooms and locked trolleys, with controlled access to keys. Controlled drugs (CDs) were managed in line with national recommendations. The service had processes to support ordering and continuity of supply of medicines, including same-day access to urgent medicines where required. Staff completed e-learning and competency checks annually or more frequently if required. There were systems in place for learning from incidents and responding to MHRA (Medicines and healthcare products Regulatory Agency) safety alerts. Internal auditing was completed routinely and the service also had external audit oversight through six‑monthly pharmacy audits.

However, we could not be assured that time‑critical Parkinson’s medicines were always administered in line with prescribed timings. The administration records showed doses recorded significantly early or late (sometimes by hours), and the rationale for these variations was not consistently documented. There was limited evidence available on the day that timing variations had been discussed and agreed with relevant clinicians or specialists. Some entries suggested late documentation rather than late administration, which did not fully account for the overall pattern seen. This was important because Parkinson’s medicines are time‑critical and significant timing variation can increase the risk of deterioration. In addition, care planning did not consistently reflect medicines‑related risk in two areas: falls documentation did not clearly show how bleeding risk was considered for people prescribed oral anticoagulants (medicines used to thin blood), and fire‑risk assessments for paraffin‑based/emollient skin products were not consistently in place or kept up to date. These issues reduced assurance that medicines risks were always assessed, mitigated and documented consistently.

Concerns around time critical medication was raised with the service. After the assessment, the service confirmed they had sought clarification from the Parkinson’s Team around potential risks in delayed/early administration of medication and they had updated documentation accordingly.