Aquarius Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care, supported learning and innovation, and promoted an open, fair culture. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The provider was previously in breach of the legal regulation in relation to good governance. Improvements were not found in this assessment, and the provider remained in breach of this regulation.

This service scored 43 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The service had not been able to develop a shared vision, strategy and culture due to the regular changes in the management of the service. In the absence of a manager, the provider had not taken an active role in ensuring staff understood the aims and objectives of the service. As a result, the new manager was spending considerable time in making sure staff shared the values of the service and knew how to put them into practice.

The service lacked processes that help to ensure an open culture. The service did not have effective systems in place to demonstrate it listened to and acted upon suggestions as they had not gained feedback from people, staff and relatives. Systems did not help identify and make service improvements or that lessons were learned.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. There had not been consistent leadership at the service which had impacted on outcomes for people. One person told us, “I have lived in a few places, and this is the worst place I have ever been. There must be something wrong with them up there as there have been so many managers in the last 2 years.” The lack of oversight of the service had led to the management team telling us they felt overwhelmed and frustrated by the amount of work they needed to complete to bring the service to the required level. The management team described how the previous manager had stopped some systems that had worked well, and they were now having bring these back which took time to complete. The management team were motivated to make the necessary changes, but this additional work could have been avoided if there had been better oversight of the service. The management team were not able to give all the support they would like to the staff team. There were complex processes for staff to be able to take their annual leave and any time owing to them. Staff supervisions which provide opportunities for staff to receive positive feedback and motivate them in their role, had not taken place due to manager’s competing priorities.

People did not always feel they could speak up and that their voice would be heard. Despite the provider having a ‘Freedom to Speak Up’ policy in place, the service could not robustly demonstrate they had always paid due attention to this or had used it to inform practice. Although staff told us they felt able to voice their views we found limited evidence that they were encouraged to do so. At staff meetings staff were given a few instructions with regards to their daily roles. There was little evidence staff had the opportunity for discussion or to ask questions. When staff views had been recorded and a request made to the provider, there had been no discussion about what the outcome had been at the following staff meeting. These actions did not reflect a positive culture where people felt they could speak up and be assured that their voices would be heard, and their suggestions acted upon.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff had received training in equality and diversity and the service had a diverse workforce. However, we found staff had not always been treated fairly and equitably according to the provider’s policy. For example, staff were expected to work and complete tasks essential to their role in their own time.

Flexible working was in place to support staff, who gave us examples of how this had supported them in relation to childcare responsibilities.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had continued to fail to ensure there were effective governance systems at the service. This was despite sending us an action plan after our last inspection of the service giving assurance that all shortfalls in the management of risks and oversight had been addressed.

The provider told us after our last inspection that auditing processes had been reviewed and new audits were in place. However, there were no structured audits to help identify any shortfalls in the service so improvements could be made. There was an informal process to identify areas where the service needed to improve whereby each member of the management team had a handwritten list of tasks that needed to be completed. However, these actions had not been prioritised in the order in which they were to be completed, nor was there a timescale setting out when it was expected they would be completed so that progress could be monitored.

The lack of auditing processes meant the provider had failed to identify shortfalls identified during this assessment. There was a failure to maintain accurate, complete and contemporaneous record of people’s care and treatment. For example, records showed that one person had fallen 8 times in 2 weeks. However, the management team told us this was not accurate as some of these falls included when the person had been admitted to hospital. Accurate records are essential to provide people with the care and treatment they need.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Information about people’s care and treatment was kept in different places in the electronic system and in paper records, so it was not easy to understand the care and treatment people had received or when professional advise had been sought and acted on. The service worked in collaboration with other partners and had received positive feedback from health care professionals. One healthcare professional told us, “It is always a pleasure to visit, the staff are welcoming and compassionate. They treat the residents with dignity and respect and focus on providing a safe and comfortable space for the residents to feel they are at home”.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Learning from events and making improvements was not at the core of service delivery. The management team had focused their time on assessing whether they could meet the existing needs of people living at the service. This had involved some people being transferred to more appropriate services, limiting their ability to identify and address shortfalls in the service as described throughout this report. When staff had reported incidents, the manager had not reviewed or investigated them to ensure that appropriate action had been taken to keep service users safe. There were 21 incidents and 58 accidents dating back to 21 October 2024 that had not been reviewed by the manager. Most of these incidents were in relation to service users falling but also included when service users had become distressed. As these events had not been reviewed, common themes and patterns had not been identified which may have led to a change in a person’s support to reduce the risk of a recurrence.

The service had failed to involve people, their relatives, and staff in developing and improving the service. There were no feedback systems or face to face meetings with people or relatives to get ideas about how to improve people’s quality of life. Nor were there any reflective discussions with staff about how to learn from incidents and problem solve.