CQC report explained · a nursing home
What the CQC found at Aspen Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, suitable recruitment checks, safeguarding procedures and safe medicines systems. A few staff employment records did not explain gaps between jobs, and some PRN medicine protocols were not personalised.
- Effective?
- Requires improvement
- People's healthcare and nutritional needs were generally supported, but some people had to wait for meals or drinks. Records did not always explain best-interest decisions or why less restrictive options for bedrails had not been used.
- Caring?
- Good
- People and relatives spoke highly of staff, and inspectors observed kindness, privacy and support for independence. There were also some occasions when staff were less person-centred or did not engage positively.
- Responsive?
- Good
- Care plans were regularly reviewed and staff understood people's needs. The home offered individual and group activities, supported communication needs and handled complaints effectively, although some care plans needed more detail about personal preferences.
- Well-led?
- Good
- Inspectors found clear leadership, approachable management and monitoring systems covering areas such as accidents, care planning, nutrition and the environment. People, relatives and staff were asked for their views.
What inspectors found, March 2019
Rated Good overall; inspectors found safe, kind care, but Effective Requires Improvement because mealtimes and some decision records needed improvement.
Inspectors made an unannounced comprehensive inspection over 19 and 20 February 2019. They spoke with people living there, relatives and staff. They reviewed care records, medicines records, staff employment records, complaints and quality checks.
The home was rated Good overall. Safe, Caring, Responsive and Well-led were also rated Good. Inspectors found enough staff, safe medicines systems, kind staff and a range of activities.
Effective was rated Requires Improvement. Some people had to wait for help or drinks at mealtimes, and staff did not always make meals a sociable experience. Records did not always show how best-interest decisions had been reached, and some fire training needed updating.
The overall rating was unchanged from the previous inspection in August 2016. The report says there was no evidence of serious risks or concerns that would change the overall Good rating.
People felt safe
People said they felt safe, and inspectors saw people who had difficulty communicating appearing comfortable and relaxed with staff.
“People were observed to be comfortable and relaxed with the staff who supported them.” from the report
Enough staff
Inspectors found sufficient staff on duty to meet people's needs and keep them safe.
“People had sufficient numbers of staff around to keep them safe and ensure their needs were met.” from the report
Kind and respectful care
People and relatives were very positive about staff. Inspectors saw kindness, respect for privacy and support for independence.
“People told us their privacy and dignity was maintained and respected.” from the report
Activities and communication
The home offered activities seven days a week, including individual support, group events and activities outside the home. Staff were also learning ways to communicate visually with people.
“People continued to be supported to participate in various activities, organised by an activities coordinator and assistants, seven days a week.” from the report
Open leadership
Inspectors found approachable leadership, regular monitoring and systems for using feedback to make improvements.
“The provider's governance framework helped monitor the management and leadership of the service, as well as the ongoing quality and safety of the care people were receiving.” from the report
Mealtimes were not always person-centred
needs fixingSome people waited for help with meals and were not told how long they would wait. Inspectors also saw staff standing over people rather than sitting beside them and engaging in conversation.
“We also saw that a few staff stood over people while assisting them with their meal rather than sat beside them and engaging in conversation.” from the report
Drinks were not always available when wanted
needs fixingOne person asked for tea but was initially told to wait for the drinks trolley. Inspectors raised this with the home.
“However, we saw that people did not always have access to drinks when they wanted them.” from the report
Decision-making records were incomplete
needs fixingRecords did not always show how best-interest decisions had been made, including decisions involving restraint and bedrails. The home said it would address this immediately.
“Although people's capacity to consent to aspects of their care had been assessed, it was not always clear how best interest decisions had been reached when people lacked capacity.” from the report
Some training needed updating
minorMost staff training was up to date, but two staff needed their fire training updated.
“The training records showed that most staff were up to date with their training and the registered manager was making arrangements for the two staff who needed updating on their fire training.” from the report
- 01What changes have been made to make mealtimes more patient, sociable and person-centred?
- 02How do you make sure people can get the drink they ask for without unnecessary waiting?
- 03How are best-interest decisions, restraint and bedrail use recorded and reviewed?
- 04Have all staff now completed the fire training that needed updating?
- 05How do care plans record personal preferences such as clothing, shaving and daily routines?
This was an unannounced comprehensive inspection covering all five areas: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 26 March 2019 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, September 2016
Rated Good; inspectors found safe, kind and personalised care, with activities being developed and a management change underway.
This was an unannounced inspection on 18 and 19 August 2016. Inspectors spoke with people, relatives and staff. They observed care and mealtimes, and checked care plans, staff files, medicines records and rotas.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, personalised care plans and staff who were kind and knew people well.
The home was supporting 42 older people living with dementia. Some people could not explain their experiences, so inspectors also relied on observations, records and discussions with relatives and staff. The registered manager was leaving, and another manager was waiting for a CQC interview to become registered manager.
Kind and respectful care
Staff knew people well and used calm, reassuring communication. Inspectors saw staff treating people with dignity and spending time with those who were quiet or did not have visitors.
“Staff had good communication skills and were kind, caring and compassionate in their interaction with people.” from the report
Staffing and training
The home had enough staff to meet assessed needs. Staff received induction, role-related training and regular supervision.
“There were sufficient numbers of staff deployed to ensure people's needs were met.” from the report
Personalised care
Care plans recorded people's backgrounds, preferences, health needs and wishes. Staff used this information to provide individual support.
“Care plans were personalised to each individual and contained information to assist staff to provide care in a manner that respected their needs and individual wishes.” from the report
Quality monitoring
The home used audits, meetings, surveys and reviews to check care and gather views. Inspectors found records well kept, accessible and secure.
“There were systems in place to monitor the quality of the service, ensure staff kept up to date with good practice and to seek people's views.” from the report
Managerial change
minorThe registered manager was leaving the home. Another manager was waiting for a CQC interview before becoming the registered manager.
“The registered manager was leaving the service.” from the report
Activities still being improved
needs fixingThe home had activities and outings, but was planning to make them more personal to individual interests.
“The registered manager told us they planned to move away from group activities in the future, to ensure that activities were more "person centred".” from the report
Complaint not yet finished
minorThe complaints process was in place and complaints were investigated, but one complaint had not been resolved by the provider when inspectors visited.
“However one complaint was still being addressed by the provider.” from the report
- 01Who is now the registered manager, and how was the handover from the previous manager managed?
- 02How are activities matched to each person's interests, history and abilities?
- 03What was the outcome of the complaint that was still being addressed at the inspection?
- 04How do you decide how many staff are needed on each shift, including weekends?
- 05How will you involve our relative and family in reviewing the care plan?
This was an unannounced comprehensive inspection covering all five CQC questions, although inspectors had limited direct conversations with some people because of their complex needs. This explanation was written from the published report of 27 September 2016 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
2 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 January 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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