Sir Aubrey Ward House

Updated 25 August 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was conducted by two inspectors, a medicines inspector and two Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Sir Aubrey Ward House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Sir Aubrey Ward House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 14 people who lived at the home and 12 relatives. We spoke with 17 staff in a range of roles, including care staff and agency staff, senior staff, the chef, auxiliary staff, the registered manager, operations manager, physiotherapist, and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with a visiting District Nurse.

We sent questionnaires to 48 staff and the care home provided CQC’s contact details to people’s relatives to invite them to provide feedback. We looked at some of the home's records. This included parts of 11 people's care plans, four staff recruitment files, three agency staff checks and staff training records. We checked a sample of internal audits, monitoring reports and records of complaints. Other records included health and safety information and a sample of policies and procedures. We observed mealtimes in different parts of the home and a handover meeting between the registered manager and staff. We checked medicines practice including observation of a medicines round, completion of administration records for eight people and storage of medicines.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We spoke with the care home’s quality manager about monitoring systems. We looked at the home’s service improvement plan, quality checks, additional care plans and nutrition and hydration data. All information requested was sent to us promptly.

Updated 25 August 2022

About the service

Sir Aubrey Ward House is a residential care home providing accommodation and personal care for up to 60 people aged 65 and over. Twenty nine people were living there at the time of the inspection.

People can be accommodated in one of four separate wings, each of which has separate adapted facilities. One of the wings specialises in providing care to people living with dementia. Two wings were not in use at the time of this inspection.

People’s experience of using this service and what we found

Quality monitoring and risk management had improved to protect people from the risk of harm and abuse. We found staff had not routinely followed some safe procedures such as testing water temperatures and documenting catheter care checks. These areas had not been identified through checks and audits. The registered manager and quality manager took immediate action to address these gaps.

People’ emotional and physical needs were assessed. We observed and people told us staff were knowledgeable and skilled in meeting people’s needs. Some care records did not always demonstrate how staff followed people’s care plans when people were in distress. The registered manager provided an action plan about how to improve this with staff.

People using the service and their relatives were positive about the management of the service and standards of care people received. For instance, “The home has much improved since [the registered manager] arrived and I hope they stay”, “I am amazed how good staff are. Nothing could go wrong. I think it is [well managed]. There are good days and bad days”, “I have no concerns, [family member] has a wash or a bath and always looks presentable and I feel they are safe without a doubt”, “The carers are friendly and polite, they are welcoming and make the family feel relaxed and it feels like home to me. Sometimes I just turn up and have my dinner with them”, “It couldn’t be better [here]. The girls are very good. They look after you. Anything you want, you just call” and “[Staff] listen. They get to the stage when they just know”.

The home was comfortable and accessible to people and was well maintained and clean. Hygienic practices and COVID-19 protocols were followed to prevent infections. People were supported to access the community and receive visitors; “We are able to visit [family member] pretty much as normal except we sign in and the home still likes us to wear a mask”.

Medicines were managed safely. People were given their medicines as prescribed. Care plans had the necessary medicines risk information about prescribed medicines.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 13 December 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 10 December 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced focused inspection of this service on 27 October and 3 November 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, safeguarding, good governance, the management of complaints, reporting statutory notifications to CQC, nutrition and hydration, dignity and respect, need for consent and enough suitable staff.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sir Aubrey Ward House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.