CQC report explained · a residential care home
What the CQC found at Sir Aubrey Ward House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments, staffing, medicines and infection control had improved. However, staff did not always record catheter care or test water temperatures as required, and one safeguarding referral was delayed after a high-risk medicine was omitted.
- Effective?
- Good
- People's health, nutrition and hydration were monitored more effectively, and staff had improved training and support. Some records did not show care being delivered in line with plans, and meal choices did not always follow dementia best practice.
- Caring?
- Good
- This question was not covered by this focused inspection. The rating was carried over from the previous inspection.
- Responsive?
- Requires improvement
- This question was not covered by this focused inspection. The rating was carried over from the previous inspection.
- Well-led?
- Requires improvement
- Leadership and monitoring had improved, with better audits, records and action plans. Some checks were still not effective enough to identify gaps in equipment records, behaviour records and follow-up of required notifications.
What inspectors found, August 2022
Sir Aubrey Ward House was rated Requires Improvement and is no longer in special measures; inspectors found clear progress but some safety checks and care records were not reliable.
This was an unannounced focused inspection on 4, 10 and 15 August 2022. Inspectors checked whether earlier problems had been fixed. They spoke with people, relatives, staff and a healthcare professional, and reviewed care plans, medicines, staffing, training, complaints and quality checks.
There had been major improvement since the previous inspection, which had rated the service Inadequate. The home was no longer breaching regulations and left special measures. Medicines, staffing, infection control, nutrition monitoring and safeguarding systems had improved.
However, some important procedures were still not followed consistently. These included recording catheter care, testing water temperatures and keeping some distress-related care records in line with care plans. Quality checks had not always found these problems. The overall rating was Requires Improvement, with Safe and Well-led rated Requires Improvement and Effective rated Good.
Improved risk management
Risk assessments were regularly reviewed and usually contained information about hazards and ways to reduce them.
“People's risk assessments were regularly reviewed and contained enough information about hazards to people and actions to reduce risks.” from the report
Medicines management
Medicines were stored securely, with checks and protocols in place. Staff training and reviews of medicine errors had also improved.
“Medicines were stored safely and securely, including controlled drugs (CDs).” from the report
Kind and respectful care
Inspectors observed staff treating people with dignity. People appeared relaxed and content, and staff knew people well.
“Staff treated people with dignity and respect and people appeared relaxed and content.” from the report
Better quality monitoring
The home had introduced wider audits, mentoring and workshops, and had made steady progress with care plans, assessments and staff training.
“Quality monitoring records showed a more robust approach to auditing a wide range of areas of quality and compliance since April 2022.” from the report
Safety procedures not always followed
needs fixingStaff did not consistently record catheter care or test and record water temperatures. The report found no evidence of harm, and action was taken during the inspection.
“Staff did not follow the home's procedure for testing and recording water temperatures to reduce the risk of scalding.” from the report
Delayed safeguarding referral
seriousOne referral about neglect and risk of harm was delayed after a high-risk medicine was omitted. Procedures were reviewed afterwards.
“One safeguarding referral was delayed in relation to neglect and risk of harm due to staff omitting a person's high-risk medicine in error.” from the report
Care records did not always match care plans
needs fixingSome records did not show that staff followed the agreed approach when people were confused or distressed. The manager took action after inspectors raised this.
“Some daily care records written by staff were not in step with people's care plans or best practice for people who experienced confusion and distress.” from the report
- 01How do you now check and record water temperatures and catheter care on every relevant shift?
- 02What changes were made after the delayed safeguarding referral involving a high-risk medicine?
- 03How do managers check that staff follow people's care plans when someone becomes distressed or confused?
- 04How are mattress settings, behaviour records and other care records audited, and how do you prove that problems are followed up?
- 05What is being done to offer people with dementia suitable meal choices and better-positioned tables?
This was a focused inspection of Safe, Effective and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 25 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2021
Sir Aubrey Ward House was rated Inadequate and placed in special measures; inspectors found people at risk from unsafe care, poor staffing and weak management.
This was an unannounced focused inspection. Inspectors visited on 27 October and 3 November 2021. They spoke with people, a relative and staff, and checked care plans, medicines, training, audits, complaints and safety records.
The overall rating fell from Requires Improvement to Inadequate. Safe, Effective and Well-led were all rated Inadequate. Inspectors found risks from poor staffing, unsafe medicines practice, missed safeguarding referrals, infection control problems, weight loss and weak records.
People were not always treated with dignity or supported with distress, personal care, food and drink. Staff did not always understand people's histories or needs. The provider had not acted sufficiently on concerns from the previous inspection.
The home was placed in special measures. The regulator requested an action plan and said it would work with the local authority and re-inspect, usually within six months, to check for significant improvement.
Recruitment checks
The report found appropriate checks had been completed before temporary and permanent staff started work.
“Recruitment records showed appropriate checks were undertaken before staff started working at the service. This included temporary care workers.” from the report
Building maintenance
The premises were maintained and basic checks were carried out on water, gas and electricity supplies.
“The premises had been well-maintained. We saw checks had been made to ensure water, gas and electricity supplies were safe.” from the report
Some positive experiences
Some people and relatives said staff were friendly, polite and caring, although feedback overall was mixed.
“Some people spoke positively of the support they or their family members received.” from the report
Some infection measures
Inspectors were assured that the home was meeting shielding and social distancing rules, using protective equipment and arranging testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
People at risk of harm
seriousStaff did not consistently recognise or report safeguarding concerns. The report said people could be exposed to avoidable harm and improper treatment.
“The provider failed to ensure systems and processes were in place and followed to prevent abuse. This placed people at risk of harm.” from the report
Insufficient staffing
seriousStaffing levels and deployment did not consistently meet people's needs, including at night. Frequent staff changes also meant staff lacked knowledge of people's histories.
“A community healthcare professional told us about five occasions this year where they felt there were not enough staff to support people.” from the report
Unsafe medicines practice
seriousStaff did not always follow safe procedures when giving or recording medicines. Storage, controlled drug access and instructions for some medicines also needed improvement.
“One member of staff signed for medicines as being administered on the Medicine Administration Records (MARs) before administering them.” from the report
Weight loss and poor nutrition support
seriousPeople were at risk of malnutrition and dehydration. Inspectors found inaccurate assessments and records, and saw someone left without help to eat.
“We found records showed excessive weight loss in short timeframes.” from the report
Poor dignity and personal care
seriousPeople were not always supported with their personal care, preferences or distress. Inspectors saw people left without reassurance and communal toilet privacy was not always maintained.
“We observed staff failed to ensure people's dignity when they used communal toilets. We observed the door left open when someone was using the facility.” from the report
Weak management and records
seriousThere had been frequent management changes. Audits did not lead to improvement, complaints records were incomplete and care records were inaccurate or contradictory.
“We found people's records were either incomplete, inaccurate or contradictory. There was no order to people's records.” from the report
- 01What has changed since the inspection to ensure there are enough staff on every shift, especially at night?
- 02How are people's weight, fluid intake and nutritional risks now assessed and reviewed?
- 03How are medicines, including as-required medicines and controlled drugs, now checked and recorded safely?
- 04How are safeguarding concerns, accidents and incidents reported, investigated and used to prevent them happening again?
- 05What evidence can you show of progress against the action plan while the home is in special measures?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed and no new ratings were given for them. This explanation was written from the published report of 11 December 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Sir Aubrey Ward House
6 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- August 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2021Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateWell-led: Inadequate
- January 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2017Goodstayed GoodSafe: Requires improvement
- June 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 29 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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