CQC report explained · a residential care home
What the CQC found at Aspen Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2018
Rated Good; inspectors found safe, kind and personalised care, with improvements recommended for dementia-friendly surroundings and end-of-life planning.
Inspectors visited without warning on 10 and 11 July 2018. They spoke with people living in the home, relatives and staff, observed care, and checked care plans, medicines records, staff files, rotas, incidents and audits.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were kept safe, received suitable care, were treated with kindness and dignity, and had care tailored to their needs.
There were some areas to improve. The home was asked to improve its physical environment for people living with dementia and to seek guidance on recording end-of-life wishes. Some care plans also lacked enough detail about managing diabetes and a respiratory condition.
The overall Good rating stayed the same as at the previous inspection in December 2016. Inspectors also found that the home had improved how it submitted required notifications.
Kind and respectful staff
Inspectors saw staff listening to people, offering comfort and protecting their privacy and dignity. People and relatives also described staff as kind and respectful.
“People and relatives told us they were always treated with kindness, compassion, dignity and respect.” from the report
Safe medicines and premises
Medicines records were completed correctly, and medicines were stored and disposed of safely. The home also maintained safe premises and equipment.
“People received their medicines safely from appropriately experienced and qualified staff.” from the report
Personalised care
Staff knew people's personal histories, preferences, communication needs and health needs. People were involved in creating and reviewing their care plans.
“People received care and support which was personalised and reflected their preferences and wishes.” from the report
Open management
The managers encouraged feedback from people, relatives and staff, and used audits to track improvements. Required statutory notifications had been submitted since the previous inspection.
“The service was open and honest when things went wrong.” from the report
Dementia-friendly environment
needs fixingThe home had some dementia-friendly signs, but the surroundings did not fully help people living with dementia to move around independently. Inspectors recommended changes in line with dementia-friendly guidance.
“People with dementia were not enabled to live independently by an appropriate environment.” from the report
Incomplete health information in care plans
needs fixingSome care plans did not explain in enough detail how diabetes or a respiratory condition should be monitored and managed. The manager acted during the inspection to update the plans.
“Information about managing people's physical health conditions was not always detailed or present in care plans.” from the report
End-of-life planning
needs fixingEnd-of-life wishes were recorded only in limited detail, and one record had no information about wishes for care or after death. Inspectors recommended seeking advice and guidance on advance care planning.
“People's records contained limited information and one record contained no information in relation to their wishes for care at the end of their life or their wishes after their death.” from the report
Activities
minorActivities took place, but one person and one relative felt there were not enough activities and that they had decreased. The home was recruiting an activities coordinator and staff were supporting activities in the meantime.
“Another person told us, "There's not enough activities, it gets very boring.” from the report
- 01What changes have you made to the physical environment to help people living with dementia find rooms and move around independently?
- 02How do you now record and monitor blood glucose levels and signs of problems for people living with diabetes?
- 03How do you record each person's end-of-life wishes, including wishes about care and what happens after death?
- 04What activities are currently available, and how do you make sure they reflect each person's interests and preferences?
- 05How do you make sure staffing is sufficient during busy morning periods?
This was an unannounced inspection covering all five CQC questions, and the overall Good rating remained unchanged from the previous inspection. This explanation was written from the published report of 29 August 2018 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, December 2016
Rated Good overall; inspectors found safe, kind care, but the home was rated Requires Improvement for being well-led because not all incidents had been notified to CQC.
This was an unannounced focused inspection on 12 and 15 November 2016. It followed concerns about staffing, staff conduct and management. Inspectors looked only at whether the home was safe and well-led.
Inspectors found enough staff to meet people's needs. People and relatives said they felt safe and were treated with kindness and respect. Staff understood safeguarding and people's risks. Concerns about cold bedrooms, children distracting staff and a lack of cook were not supported by what inspectors found.
The home was rated Good for safe care. It was rated Requires Improvement for being well-led because the provider had not notified CQC about all incidents. Inspectors also found hazardous substances accessible in the garden on the first day, although these were locked away by the second day.
The overall rating was Good. Inspectors said they could not change the ratings because this would require consistent good practice over time. They planned to check this again at the next comprehensive inspection.
Enough staff
Inspectors found enough staff to meet people's needs. Staff were not rushed and responded promptly and compassionately.
“There were enough staff to meet people's needs and staff knew how to identify, prevent and report abuse.” from the report
People felt safe
People and families said they felt safe, comfortable and well supported. Inspectors saw staff treating people with kindness and respect.
“People and their families told us they felt safe and were treated with respect.” from the report
Safeguarding knowledge
Staff had recent safeguarding training and knew how to recognise and report concerns.
“All staff received an update in safeguarding training less than six months ago.” from the report
Open management
Staff and families said the manager was available and supportive. Staff meetings gave staff opportunities to raise ideas and concerns.
“Staff meetings were carried out regularly.” from the report
Incidents not always reported
needs fixingThe provider had still not notified CQC about all incidents involving people at the home. This led to the Requires Improvement rating for well-led.
“The provider had still not notified CQC of all incidents' involving people living at the home.” from the report
Hazardous substances accessible
seriousOn the first inspection day, hazardous substances were accessible to people in the garden. They had been locked away by the second day.
“on the first day of our inspection we found substances hazardous to health were accessible to people in the garden.” from the report
Fire system upgrade
needs fixingA fire service had recommended upgrading the system to meet current British standards. The manager had arranged a meeting with the service provider about this.
“However, there was a recommendation from a fire service earlier in the year to upgrade the system to comply with current British standards.” from the report
- 01What changes have you made to make sure every incident involving a resident is notified to CQC when required?
- 02How are hazardous substances kept locked away from residents at all times?
- 03Was the fire alarm system upgraded to comply with current British standards, and when was this completed?
- 04How do you check that staffing levels remain sufficient at weekends and when staff are absent?
- 05What will you do to show consistent good practice before the next comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other three key questions were not covered in this report. This explanation was written from the published report of 22 December 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 Lodge Care Home
3 rated inspections over 3 years: the service has held its Good rating throughout.
- August 2018Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Goodstayed GoodSafe: GoodWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
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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