CQC report explained · a residential care home
What the CQC found at Aspen Lodge Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2021
Aspen Lodge Residential Care Home was rated Good; inspectors found safe care and improved management, with some redecoration still needed.
This was an unannounced focused inspection on 06 October 2021. Inspectors checked whether the home had improved its Safe and Well-led services after a previous inspection found legal breaches. They spoke with people, a relative, staff and a healthcare professional. They also checked care plans, medicines, health and safety records and staff recruitment.
The home was rated Good overall, with Good ratings for Safe and Well-led. People were protected from abuse, risks were assessed, medicines were given safely and there were enough staff. Infection control arrangements were mostly effective, although some areas needed redecoration.
The previous rating was Requires Improvement, published in March 2021. Inspectors found enough improvement for the home to no longer be in breach of the regulations linked to Safe and Well-led. The other key questions were not inspected during this visit, so their previous ratings were used in the overall rating.
Safeguarding
Staff understood how to recognise and report abuse or other concerns. The provider had systems for referring concerns to other organisations.
“People were protected from the risk of abuse and ill treatment as staff members had received training on how to recognise and respond to concerns.” from the report
Medicines
Staff were trained and assessed as competent to give medicines. Regular checks were carried out on storage and administration.
“People were supported to receive their medicines safely and as prescribed.” from the report
Staffing
Inspectors found enough staff to support people safely and promptly. Recruitment checks included checks with the Disclosure and Barring Service.
“People were supported by enough staff to safely assist them and to respond to them in a timely way.” from the report
Management
The management team used checks on care plans and medicines to monitor quality. People found managers approachable and supportive.
“The provider and management team had effective quality monitoring systems.” from the report
Involvement
People were asked about their choices, activities and daily routines. Families were kept informed and asked for their views.
“People told us they felt involved.” from the report
Some areas need redecoration
minorInspectors were only somewhat assured about the safety of the premises' layout and hygiene practices because some areas needed redecoration.
“We were somewhat assured the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
- 01Which areas needed redecoration at the inspection, and has this work now been completed?
- 02How often are care plans and risk assessments reviewed, and what happens when a person's needs change?
- 03How are medicines checks completed, and how are errors or suspected errors followed up?
- 04What infection control arrangements are currently used for visitors, testing, PPE and possible outbreaks?
- 05What were the previous safeguarding and governance problems, and how does the home check that the improvements are being maintained?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 16 October 2021 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, March 2021
Requires Improvement; inspectors found people were generally supported, but failures in abuse reporting and oversight left people at risk.
This was a focused inspection on 26 January 2021. Inspectors looked at Safe, Effective and Well-led after concerns about safety and to check infection control during the COVID-19 pandemic. They spoke with one person, two relatives, seven staff and two health professionals, and reviewed care, medicine and management records.
The home had enough staff, medicines were managed safely, infection control arrangements were suitable, and people said they felt safe. Staff understood people's care and health needs. The Effective rating improved from Requires Improvement to Good.
However, five incidents involving possible physical abuse or assault had not been sent to the right outside body for investigation. The home also failed to identify and report some safeguarding incidents properly. Its systems for checking safety and quality were not strong enough, so Safe and Well-led were rated Requires Improvement.
The overall rating remains Requires Improvement. This is the home's second consecutive rating at this level. The provider must send an action plan, and CQC said it will monitor progress and return for another inspection.
Enough staff
People, relatives and staff said there were enough staff, and inspectors saw staff respond when people needed help.
“Our observations supported this as staff were able to offer support to people when they needed it.” from the report
Medicines managed safely
Inspectors found clear instructions, safe storage and accurate medicine records. Staff followed the home's procedures.
“We saw staff followed the medicines procedures when administering people's medicines.” from the report
Infection control
The home was meeting the infection prevention measures checked during the pandemic, including use of protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Good food and health support
People had choices of food and drinks, with monitoring and support where they were at risk from poor nutrition or fluid intake. Staff involved health professionals when needed.
“People had a choice of meals and drinks and their needs assessed for support and where required monitoring was in place.” from the report
Possible abuse was not referred
seriousFive recorded incidents of possible physical abuse or assault had not been sent to the appropriate outside body for investigation. Inspectors said this left people at risk of harm.
“We found five incidents which had been documented by staff in the providers incident report forms however, these had not been sent to the appropriate body for external review and investigation.” from the report
Weak management checks
seriousThe home's governance systems did not identify failures in abuse reporting and did not ensure all required notifications were made to CQC.
“Systems and processes to review incidents of potential abuse and ensure people were safeguarded from abuse were not robust and people were left at risk of harm.” from the report
Care risk information was still being developed
needs fixingThe new electronic care planning system did not yet fully explain how some risks, including catheter and pressure care, should be managed. Paper records were supplied after the visit.
“The system did not fully reflect how to mitigate risks for example with catheter care and pressure care in peoples care plans.” from the report
- 01What changes have you made to ensure every possible abuse incident is referred to the appropriate outside body?
- 02How do you now check that safeguarding incidents and other legally required notifications are reported to CQC on time?
- 03Has the electronic care planning system been fully updated for catheter care, pressure care and other safety risks?
- 04What is the current position on staff training that was not up to date at the inspection?
- 05What progress has been made on the action plan requested by CQC, and when is the next reinspection expected?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and earlier ratings were used in calculating the overall rating. This explanation was written from the published report of 23 March 2021 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 Residential Care Home
4 rated inspections over 4 years: the service has held its Good rating throughout.
- October 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Aspen Lodge Residential Care Home →
- March 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Aspen Lodge Residential Care Home →
- March 2020Requires improvementdown from GoodSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- July 2017GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2016
Registered with the Care Quality Commission on 18 June 2016.
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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