CQC report explained · a nursing home
What the CQC found at Aspen Court Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risk assessments and care plans were missing or lacked enough detail, creating a risk to people's health and safety. Staff numbers, medicines management, safeguarding systems and infection control were otherwise found to be suitable during the inspection.
- Effective?
- Requires improvement
- Some staff had not received regular one-to-one supervision. Assessments for some people with mental health conditions lacked detail, although people generally received healthcare support and had their eating, drinking and consent needs considered.
- Caring?
- Good
- People and relatives spoke positively about staff kindness and respect. Inspectors observed compassionate interactions, privacy being respected and people being supported to make choices.
- Responsive?
- Requires improvement
- Some communication and personalised care plans did not give staff enough guidance. Activities were taking place, but there was little meaningful engagement on two floors on some inspection days.
- Well-led?
- Requires improvement
- The new manager had introduced daily meetings, walkarounds and monitoring, and improvements were reported. However, staff feedback included concerns about fear, reprisals, bullying, intimidation, complaints and pay, while communication still needed improvement.
What inspectors found, November 2022
Rated Requires Improvement; inspectors found kind care and enough staff, but gaps in risk records and recruitment created safety concerns.
Inspectors visited the home without notice on 21, 22 and 23 September 2022. They spoke with people, relatives, staff and health professionals. They observed care, meals, medicines and infection control, and reviewed care, medicines, staff and management records.
People were generally treated with kindness, dignity and respect. Staff responded patiently and promptly. There were enough staff during the inspection, medicines were managed safely, people could access healthcare, and infection control arrangements were considered suitable.
However, some care plans and risk assessments were incomplete or unclear. This included risks linked to pressure sores, moving and handling, falls, choking and communication. Staff recruitment checks were not always fully recorded, and some staff had not received regular one-to-one supervision.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were rated Requires Improvement, while Caring was rated Good. The home remained in breach of two regulations, and the provider was asked for an action plan and will be monitored.
Kind and respectful care
People and relatives were positive about staff kindness and respect. Inspectors saw staff respond with patience, compassion and reassurance.
“We observed positive and caring interactions throughout the inspection between people and the staff team which showed people were well cared for.” from the report
Enough staff on duty
Inspectors observed enough staff to meet people's needs promptly. People and most relatives said they felt safe because staff were available.
“Observations throughout the inspection showed there were enough staff on duty to meet people's needs in a timely manner.” from the report
Medicines managed safely
Medicines were stored safely, records were accurate and staff had training and competency checks. Inspectors saw people receiving medicines as prescribed.
“Medicines were stored safely, with accurate records for daily fridge temperatures and controlled drugs.” from the report
Access to healthcare
People were supported to see healthcare professionals when their health changed. The home had regular input from a GP and other professionals.
“People were supported to access a range of healthcare services and appropriate referrals to a range of health and social care professionals were made when people's needs changed or their health deteriorated.” from the report
Manager taking action
The manager had introduced daily meetings, walkarounds and monitoring. The report says the home had improved in several areas since the manager started.
“Improvements had been made since the previous inspection and the provider's monitoring processes had identified areas to be improved.” from the report
Incomplete risk records
seriousSome records did not explain people's risks or the support staff needed to provide. Examples included pressure sores, moving and handling, falls and choking.
“These inconsistencies created a risk to people's health and safety.” from the report
Staff supervision
needs fixingSeveral staff said they had not received one-to-one supervision for a long time. Recent supervision records were not available for a sample of staff.
“Staff did not always receive ongoing supervision to support them in their role.” from the report
Personalised communication plans
needs fixingSome communication plans did not explain how to support people who had difficulty communicating or whose first language was not English.
“There was no communication plan in place to highlight how staff could effectively communicate with them.” from the report
Limited activities on some floors
needs fixingThere was little or no meaningful engagement for people on two floors on the first inspection day. Some improvement was seen later, but this was not consistent.
“Whilst there were activities happening on the ground floor, we observed little to no meaningful engagement for people across the two other floors on the first day of the inspection.” from the report
- 01How have you checked that every resident now has complete and detailed risk assessments for falls, pressure sores, moving and handling and choking?
- 02What system now ensures all staff receive regular one-to-one supervision, and when was each current staff member last supervised?
- 03What changes have been made to provide meaningful activities and engagement on every floor, including for people cared for in bed?
- 04What action has been taken in response to staff concerns about fear, bullying, intimidation, complaints and pay?
- 05How do staff communicate with residents who have difficulty communicating or whose first language is not English?
This was a comprehensive inspection covering all five key questions, including infection prevention and control; the previous targeted inspection in July 2022 had not changed the ratings. This explanation was written from the published report of 11 November 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, July 2022
Inspected but not rated; inspectors found safeguarding systems in place, but the previous Requires Improvement rating remains.
This was an unannounced, targeted inspection on 22 June 2022. It followed a serious incident and concerns shared by the local authority safeguarding team. The inspection checked safeguarding systems and infection prevention and control. It did not examine what happened in the incident itself.
Inspectors reviewed records and policies, observed infection control practice, and spoke with 10 staff and four health and social care professionals. They did not speak with any residents. They found systems to protect people from abuse, staff who understood safeguarding, and suitable infection control arrangements.
The home was not given a new overall rating. The previous rating was Requires Improvement, published in April 2020, and this targeted inspection did not change it. CQC said the Safe question remained Requires Improvement from the last inspection, but was inspected but not rated this time.
Safeguarding awareness
Staff had safeguarding training and regular discussions. They could describe types of abuse, warning signs and what to do if they had concerns.
“Staff had a good understanding of their safeguarding responsibilities and were able to explain in detail the types of abuse people could be at risk of” from the report
Incident learning
The home reviewed incidents and shared learning with staff. Meetings were used to discuss what happened and how future incidents might be prevented.
“There were procedures in place for the reporting of any incidents and accidents across the home and outcomes of investigations were used as a learning experience for the staff team.” from the report
Infection control
Inspectors were assured about infection control, including PPE, testing, visiting arrangements, hygiene and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Open response
The management team discussed the concerns openly with inspectors and had started identifying improvements through its own investigation.
“The management team were open and transparent when we discussed the concerns with them and the reason for the unannounced inspection.” from the report
Previous rating still Requires Improvement
needs fixingThe home was not given a new overall rating, but the previous Requires Improvement rating was unchanged. This means the report does not confirm that the wider concerns from the last full inspection have been resolved.
“The overall rating for the service has not changed following this targeted inspection and remains requires improvement.” from the report
Incident not examined
needs fixingThe inspection followed an allegation of a serious assault, but CQC did not assess the circumstances of that incident. This report therefore cannot tell families what happened or whether the allegation was substantiated.
“As a result, this inspection did not examine the circumstances of the incident.” from the report
- 01What action has been taken since the previous Requires Improvement inspection and can you show us the completed action plan?
- 02What safeguarding improvements were identified after the incident that led to this inspection?
- 03Who is responsible for managing the home while the new manager's registration application is being processed?
- 04How are safeguarding concerns, unexplained bruising, accidents and incidents recorded and reviewed?
- 05How will you keep families informed if there is an incident or safeguarding concern?
This was a targeted inspection of safeguarding systems and infection prevention and control; it did not assess the whole service or change the previous ratings. This explanation was written from the published report of 20 July 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.
Every inspection of Aspen Court Nursing Home
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- November 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2022Inspected but not ratedSafe: Inspected but not rated
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2014Inspected but not rated
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 31 October 2011.
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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