CQC report explained · a residential care home
What the CQC found at Aspen Manor Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2024
Rated Requires Improvement; inspectors found risks in care, medicines, infection control and management systems.
This was an unannounced focused inspection on 1 November 2023. Inspectors looked only at Safe and Well-led. They spoke with people, relatives, staff and a healthcare professional, observed care, and checked care records, medicines records, staff files and management records.
Inspectors found that people were not always supported to drink enough or change position to protect their skin. Medicines records were not always accurate. Some infection control practices were unsafe, and staffing arrangements did not always give staff confidence that enough people would be available when there were absences.
The home’s checks and audits did not identify or fix these problems. Safe and Well-led were both rated Requires Improvement. The overall rating changed from Good at the previous inspection, published in June 2023. The incident that prompted this inspection was not examined and remains subject to further CQC investigation.
Kind responses
Staff responded professionally and compassionately when people became distressed or verbally aggressive.
“We observed staff reacting to verbal aggression in a professional way with a kind and compassionate approach.” from the report
Recruitment checks
The provider used recruitment checks, including Disclosure and Barring Service checks.
“The provider operated safe recruitment processes. Recruitment checks were undertaken including checks with the Disclosure and Barring Service (DBS).” from the report
Positive views of the manager
People, relatives and staff gave positive feedback about the registered manager.
“People, relatives and staff were positive about the registered manager.” from the report
Known risks were not always managed
seriousRecords showed gaps in support and monitoring for food, drinks and repositioning. This included people at risk of dehydration, malnutrition or pressure sores.
“People did not always receive timely and effective support to manage known risks.” from the report
Weak management checks
seriousAudits were being completed but did not find or correct problems with care monitoring, care plans, medicines and infection control.
“The provider had not operated an effective system to assess, monitor and improve the quality and safety of the service provided.” from the report
Medicines records
needs fixingMedicine stock records contained errors. One as-required medicine did not have a protocol, and fridge temperature records did not show the minimum and maximum temperatures.
“We found errors in medicine stock quantities and records which meant medicines were not accurately accounted for.” from the report
Infection control practices
needs fixingSome equipment was stored in a communal bathroom, creating a risk of spreading infection. Cleaning schedules were not always checked by managers.
“We saw equipment such as hoists, hoist slings and a trolley with continence aids and wipes on were stored in a communal bathroom.” from the report
Staffing cover
needs fixingStaff said contingency plans did not always work effectively when there were short-notice absences. Rotas showed occasions when staffing numbers were low.
“Staff did not feel confident contingency plans were implemented effectively to ensure there were always sufficient numbers of staff deployed to meet people's needs.” from the report
- 01How are you now making sure people receive the food and drinks set out in their care plans, and how do you check this daily?
- 02How do you make sure people are repositioned when required, and what happens when someone declines support or their skin condition changes?
- 03What has changed in medicines management since the inspection, including stock checks, as-required medicine protocols and fridge temperature records?
- 04Where are hoists, slings and continence equipment stored now, and how are cleaning checks audited by managers?
- 05What action has been taken in response to the warning notice and the required action plan, and how can we see evidence that improvements are being sustained?
This was a focused inspection of Safe and Well-led only; the other key question ratings carried over from the previous inspection. This explanation was written from the published report of 16 February 2024 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, June 2023
Aspen Manor Care Home was rated Good; inspectors found safe, kind and personalised care, with some medicines procedures needing improvement.
This was the home’s first inspection. Inspectors visited on 4 May 2023 and reviewed information up to 22 May. They observed care, spoke with staff and relatives, and checked care, medicines, recruitment and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines administration, suitable training, good health support and care that respected people’s choices, dignity and independence.
The home supported people to keep in touch with relatives and take part in activities. Managers used feedback, complaints, incidents and audits to make improvements. Inspectors noted that the protocols for topical medicines, such as creams, were not always consistent, but managers said they would act immediately.
Kind and respectful care
Inspectors saw caring interactions. Relatives said staff listened to people, knew them well and respected their preferences.
“The staff are really kind and caring and [person] is listened to and respected.” from the report
Personalised care
Care records were detailed and tailored to people’s individual needs. People and relatives helped plan care and were supported to make everyday choices.
“The information on people's care records was robust and tailored to reflect the individual needs of each person.” from the report
Good activities and family links
People could take part in group activities, use social spaces and maintain links with relatives and the local community.
“People had access to a cinema, private social areas, a variety of group activities and staff who were dedicated to support their social needs and minimise the risk of social isolation.” from the report
Responsive management
Managers were approachable and acted on feedback, concerns and incidents. Quality checks identified areas for improvement.
“Managers completed a range of quality assurance checks and audits which they used to monitor the quality of care people received.” from the report
Inspectors raised no specific concerns in this report.
- 01What immediate action was taken to make the topical medicines protocols consistent?
- 02How do you review staffing numbers when residents’ needs or the home’s occupancy change?
- 03How will you make sure activities match my relative’s interests and communication needs?
- 04How will my relative and our family be involved in reviewing their care plan?
- 05How can we raise a concern or complaint, and how will you tell us what action was taken?
This was the first inspection of the newly registered home and covered all five CQC questions, including infection prevention and control. This explanation was written from the published report of 14 June 2023 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 Manor Care Home
2 rated inspections over a year: the service has slipped, from Good to Requires improvement.
- February 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2023GoodSafe: GoodWell-led: Good
- October 2021
Registered with the Care Quality Commission on 29 October 2021.
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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