CQC report explained · a nursing home
What the CQC found at Asprey Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some risk plans needed clearer information, including for self-harm risks. Inspectors also found an unlocked sluice door, a torn crash mat and damaged furniture, although the provider acted immediately.
- Effective?
- Good
- People's needs were assessed, staff were trained and supported, and health and dietary needs were managed. Inspectors noted that mealtime organisation was not consistent across all four units.
- Caring?
- Good
- The report does not give a separate Caring rating. Feedback from people and relatives included that staff were patient, kind, professional and approachable.
- Responsive?
- Good
- The report does not give a separate Responsive rating. It says people's wishes, preferences and dietary needs were known and included in care planning.
- Well-led?
- Good
- There were systems to monitor care and identify improvements. The provider responded positively and acted on issues raised during the inspection.
What inspectors found, February 2024
Rated Good overall; inspectors found effective, caring and well-led support, but safety still Requires Improvement.
Inspectors visited unannounced on 30 November and 4 December 2023. They spoke with people, relatives, staff and health professionals. They reviewed care records, medicines records, recruitment files and quality checks.
The home was rated Good overall. Effective and well-led were rated Good. Safe remained Requires Improvement, as some care plans did not contain enough information about risks and some environmental hazards were found.
People were protected from abuse, received their medicines as prescribed and had enough staff supporting them. Staff were trained and understood people's needs. The provider acted immediately on several issues found during the inspection.
The inspection was prompted partly by an incident after which a person died. CQC said it was carrying out a separate investigation and did not examine the circumstances of that incident during this inspection.
Medicines and staffing
People received their medicines as prescribed, and inspectors saw medicines being given safely. There were enough staff to support people safely, and recruitment checks had been completed.
“At this inspection people received their medicines as prescribed. We observed people being supported to take their medicines safely.” from the report
Skilled and supported staff
Staff received role-relevant training and ongoing support. People and relatives spoke positively about staff knowledge and understanding of individual needs.
“Staff received an induction and on-going training and support which helped them carry out their roles effectively.” from the report
Health and dietary support
Staff worked with health professionals and made referrals when people's needs changed. Staff understood dietary requirements, and people received enough food and drink.
“Where people had specific dietary needs, staff were aware, and people received food and drink that was safe and met their needs.” from the report
Positive leadership
Inspectors found a positive culture, with staff working professionally and collaboratively. The provider acted quickly on issues identified during the visit.
“The provider responded positively to the inspection and took immediate action where they could on issues identified during the inspection.” from the report
Risk information was incomplete
seriousSome care plans needed more information about known risks and preventive measures. This included clearer escalation information for people at risk of self-harm, although the plans were updated during the inspection.
“We discussed where there was a risk of self-harm for some people, additional information was needed, so the escalation process was clear.” from the report
Environmental hazards
seriousInspectors found an unlocked sluice door, a torn crash mat and damaged furniture. The provider removed the immediate risks on the day and planned furniture replacements.
“This included an unlocked sluice door, a torn crash mat and a damaged piece of furniture.” from the report
Infection control practice
needs fixingHand washing before meals was not consistent. The provider addressed this immediately and included it in regular checks.
“We observed hand washing for people prior to meal times, was not consistent.” from the report
Mealtimes varied between units
minorSome units were better organised and made mealtimes more enjoyable than others. The provider reviewed its mealtime checks and acted on the feedback.
“We saw some units were more organised and made the mealtime a more enjoyable experience, however this was not consistent on all 4 units.” from the report
- 01What has been done since the inspection to make sure every risk assessment contains clear preventive measures and escalation steps?
- 02How do you check that hazards such as damaged furniture, crash mats and unlocked doors are identified and dealt with promptly?
- 03How do you make sure hand washing before meals is now consistent across all four units?
- 04What changes have been made to make mealtimes equally well organised across all four units?
- 05What were the outcomes of the safeguarding investigations that were still in progress at the inspection?
This was an unannounced inspection that looked at the premises and care, with ratings reported for Safe, Effective and Well-led; the report does not give separate Caring or Responsive ratings. This explanation was written from the published report of 10 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, January 2022
Rated Good overall, but inspectors found the home was not consistently safe and rated Safe as Requires Improvement.
Inspectors visited without notice on 9 and 11 November 2021. They spoke with people living in the home, relatives, staff and health professionals. They also observed care and checked care records, medicine records, recruitment files and management systems.
The home was rated Good for Effective, Caring, Responsive and Well-led. People were treated kindly, supported by staff who knew them well, and helped to take part in activities and keep in touch with relatives. Inspectors also found good support with food, healthcare and personal choices.
Safe was rated Requires Improvement. Inspectors found gaps in recruitment checks, problems with some medicine records and practices, and areas where infection control was not fully assured. The home acted immediately on the issues identified during the inspection.
The overall Good rating means inspectors found the service generally provided good care, but the safety concerns need attention. The Safe rating had fallen from Good at the previous inspection in 2018.
Staff knew people well
People were supported by a consistent staff group who understood their needs and how to keep them safe.
“We saw people were supported by a consistent group of staff who knew them well.” from the report
Kind and respectful care
Inspectors saw staff treating people with kindness and respect. People were offered choices about their care and daily lives.
“We observed interactions between staff and people living at Asprey Court were kind, caring and respectful.” from the report
Good activities and family contact
People could join different activities, including entertainment, films and animal therapy. The home also helped people keep in contact with relatives during the pandemic.
“People were supported to take part in a variety of activities that were of interest to them.” from the report
Supportive management
Staff said they felt supported and listened to. Inspectors found the manager was visible and that the home had a culture of improvement.
“There was a positive and proactive culture of continuous improvement throughout the service.” from the report
Recruitment checks were incomplete
needs fixingThree staff files were checked and gaps were found in employment histories. One person's right to work in the UK had not been evidenced.
“gaps in staff employment history had not been explored and for one person, the right to work in the UK had not been evidenced.” from the report
Medicine systems needed improvement
seriousSome 'as required' medicine protocols were missing. Other problems included incomplete administration records, an out-of-stock medicine and a medicine trolley left unattended with its keys in the lock.
“Some protocols were missing for 'as required' medicines which meant there was a risk people may not receive these medicines consistently.” from the report
Infection control was not fully assured
needs fixingInspectors found a missing admission PCR record, staff wearing masks incorrectly, unsuitable disposal of used PPE and limited monitoring of communal bathrooms and toilets.
“We observed on several occasions staff wearing their masks under their chin.” from the report
Some audits did not find problems
needs fixingMedicine audits had not identified all the issues found by inspectors. Recruitment audits had also not recently been completed on site.
“Medication audits had not identified all areas found on inspection but action was taken to address concerns on inspection and auditing systems and processes were reviewed.” from the report
- 01What changes were made to medicine protocols and records after the inspection, and how are they checked now?
- 02How do you make sure medicine trolleys are never left unattended with the keys in the lock?
- 03What improvements were made to mask use, PPE disposal, admission testing and bathroom monitoring?
- 04How are recruitment checks, including employment histories and right-to-work evidence, now audited?
- 05What later checks or reviews show that the concerns found in November 2021 have been fully resolved?
This was an unannounced inspection covering all five key questions, including infection prevention and control under Safe; the previous overall rating was Good, published in July 2018. This explanation was written from the published report of 29 January 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 Asprey Court Care Home
3 rated inspections over 6 years: the service has held its Good rating throughout.
- February 2024Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022Goodstayed GoodSafe: Requires improvementEffective: GoodWell-led: Good
- July 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2017
Registered with the Care Quality Commission on 7 August 2017.
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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