Aquarius Care Home

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 remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to person centred care. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

The provider was previously in breach of legal regulation in relation to providing safe care and treatment. Improvements were not found in this assessment and the provider remained in breach of this regulation.

This service scored 50 (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 have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

Accidents and incidents had not been well managed. Although staff felt confident to report incidents and share them with the staff team, the service lacked management oversight of risk. Monitoring processes were not in place to analyse accidents and incidents. This meant that themes, trends and learning from events that put people at risk of harm were not used to inform the assessment of risk and the practices within the service. For example, it had been flagged on the electronic monitoring system that on 6 occasions only 1 staff member had assisted a person to mobilise. Risk assessments indicated they required 2 staff to keep them safe. The manager was not aware of this safety concern so had not investigated to identify what actions they needed to take to keep people and staff safe from harm.

There had been limited opportunities to develop a learning culture due to changes in the management and staff team. The manager had been in post for 5 months. They told us they had been unable to undertake a proactive approach as they had been focused on responding to the daily challenges of the service. The management team were motivated but had only been able to make a small number of improvements due to competing priorities of the day to day running of the service.

The provider did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider could not be assured there were robust safe systems in place for people to transition between services as some people did not have a comprehensive assessment or care plan. The provider was aware of this shortfall but had not been able to address this in a timely manner. For example, the provider had identified in December 2024 that a person who moved to the service in September 2024 did not have a comprehensive plan. This person’s care plan remained incomplete at the time of our assessment. Care plans viewed lacked hospital passports and where needed, mental capacity assessments, and people’s social history and life stories were absent.

People were supported to maintain their health, and attend appointments, both inside and outside of the service. Where routine health checks were undertaken, people had support from staff who knew them well and help them understand what was happening. One person told us, “I get to see the doctor whenever I need to.”

The provider had systems in place to work with people and partners including the local authority care managers and health professionals to establish safe systems of care. One health care professional told us, “I have not noticed any health concerns when visiting this home. If there are any issues that need a referral to me or the doctor, the management team are very prompt in doing so.”

The service maintained regular contact with the local authority as well as with the GP, the diabetic team, district nurses, podiatry and other health care professionals.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Safeguarding and whistle-blowing policies were in place but had not always been followed. Staff had received adult safeguarding training and understood their responsibilities to report a safeguarding concern. When staff had reported potentially inappropriate contact between 2 people, this had not been reviewed and actioned by the manager. This meant that appropriate referrals had not occurred in a timely way or action taken to reduce risks.

People told us they felt safe living at the service. One person told us, “I feel safe here because the staff are good, and the people are nice.” People told us they felt confident to speak with staff or the manager if they had any worries or concerns. One person told us, “I would approach any staff if I needed to. I speak my mind, and they listen.”

The management team told us they had a positive working relationship with the local authority and other statutory partners and were confident to seek advice and report safeguarding issues in a timely way.

We observed positive interactions between staff and people during our visit. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted.

Deprivation of Liberty Safeguards (DoLS) had been applied for appropriately. The provider was monitoring these applications to ensure that people were lawfully deprived of their liberty. DoLs ensures people who cannot consent to their care arrangements in a care home are protected if those arrangements deprive them of their liberty.

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.

The provider had continued to fail to have effective systems in place to identify, monitor and manage risk. Risks to people were not always identified and some risk assessments were missing or lacked enough detailed information for staff to know how to keep people safe.

Although we observed people being supported to move around the service safely, one person who had fallen several times did not have a falls risk assessment in place. Their care plan did not identify that this person was at risk of falls because it had not been updated to accurately reflect each incident and the mitigating actions taken. A falls risk assessment was only completed by the service during our inspection visit when we advised the provider of the shortfall.

Staff told us they knew how to manage situations when people became anxious. One person had become agitated on several occasions including hitting another person. There was no associated risk assessment or guidance for staff to follow to help them recognise potential triggers to minimise this occurrence. Nor were there any strategies for staff to follow to ensure staff were using a consistent approach to effectively support the person and de-escalate stress behaviours.

The provider did not always detect and control potential risks in the care environment. The provider had not ensured all actions had been undertaken to safely evacuate people in the event of a fire. Fire drills, to check staff had the practical skills needed, had not taken place with night staff and did not include the names of day staff who had participated in the drills. For people who were immobile, the service had not ensured they had the appropriate equipment in place to safely evacuate them in the event of a fire. This meant they were at risk of harm in the event of a fire. People benefited from an environment that was warm and clean. Radiators were covered. Window restrictors were in place and functional, both in communal areas and in people’s bedrooms. Corridors were laminated, swept clean and free from obstruction with safely mounted grab rails throughout. Essential servicing had taken place such as the maintenance of gas, electricity, fire alarms, emergency lighting and moving and handling equipment. The service employed a maintenance team to carry out repairs, logged in a maintenance book and kept in the manager’s office. On the day of our inspection, the maintenance team were repairing a leak to a bathroom where the floor had become wet. One staff member told us, “There is a maintenance book in the office for any repairs or damages, and these are dealt with reasonably quickly, for example, if a tap is loose.” People’s bedrooms were personalised with a framed picture and their name on the front of their bedroom door, personal photos, toys, pictures and soft furnishings present in their rooms which were tidy and clean.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The provider did not have a proactive and structured approach to making sure there were always enough qualified, skilled and experienced staff available. The management team told us they had been concerned for some time that staffing levels were not always sufficient, particularly at nighttime, and had not used a dependency tool to assess people’s support needs . Prompted by discussions during the inspection, the provider obtained a system to assess the number of staff needed during the day and night and contacted the fire service for advice.

Staff and professionals gave mixed views. A staff member told us, “We are busy at mealtimes which can be a bit manic, and when we could do with more staff.” At lunchtime, we observed staff were not able to support one person for a long period as they were called to another person who required assistance. A healthcare professional told us, “I have found the staffing levels to be slightly low at times. Weekend staffing levels appear to be a bit thin on the ground and care staff would generally appear a bit stretched.”

Although staff training had improved since the last inspection and included training specifically for people with a learning disability, there remained shortfalls with medicines training, supervision and induction. None of the nighttime staff were trained to administer medicines so were unable to provide pain relief to people if it was needed. There were not sufficient checks in place for new staff to ensure they were competent in their roles. Staff induction records were not comprehensive, staff had no review following their probation, and regular supervisions were not taking place for most 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.

People told us their bedrooms and the service were kept clean and tidy. One relative told us, “The home is very clean and there are no smells.”

Staff told us they had sufficient PPE (personal protective equipment) to provide safe care, and we saw this was available throughout the service. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. One staff member said, “I have had online training which shows you how the laundry works, how the kitchen is kept clean, bagging laundry properly, using the washing machines, how and when to wear PPE and safe hand hygiene practice.” The housekeeper told us, “We reorder all products as needed. A room a day is deep cleaned, including the bathrooms and the office.” We observed a locked cupboard for the control of substances hazardous to health (COSHH) cupboard outside the main building.

A health care professional told us, “Cleanliness never appears to be an issue when visiting. PPE is readily available and supplied to our staff is needed. Resident’s accidents are cleaned and sanitised quickly.”

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. The provider had not audited the management of medicines to identify any shortfalls nor ensured everyone had timely access to their prescribed medicines when they needed them. No night staff had been trained to administer medicines. One person had been prescribed a pain-relieving medication to be taken when needed which included at nighttime. There were no on-site staff available to provide pain relief from early evening until morning. Staff needed to contact on-call who told us they could arrive at the service between 10 – 40 minutes depending on who was on the rota. This did not give assurances to people they would receive pain relief as soon as they required it. We observed staff recording the administration of medicines on the electronic medicines administration record (MAR). Competency checks on staff who were trained to administer medication were completed yearly. Cupboards were locked and medicines were stored in accordance with national guidance. People were supported by the district nursing team who visited the service twice daily to monitor people’s health needs as they arose and to administer insulin. One relative told us, “My brother uses a lot of different lotions and creams. They are applied to different areas of the body and at different times of the day, and they never miss and application. I believe his condition is so much better because the staff know his needs well and never miss giving him his treatments and medicines.”