Background to this inspection
Updated
3 January 2024
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
Inspection team
The inspection was carried out by 1 inspector and 1 Expert by experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Aspen House Limited is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed feedback from the local authority who commissioned people’s care. We used the information the provider sent us in the provider information return. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all of this information to plan our inspection.
During the inspection
Inspection activity started on 14 November 2023 and ended on 22 November 2023. We visited the service location on 14 November 2023. We spoke with 7 people who lived at the service. We spoke with 6 staff including the registered manager, the deputy manager, 3 support workers and the chef. We reviewed the relevant parts of 3 people’s care plans and medicines administration record (MAR) charts. We looked at 3 staff recruitment files, training matrix, audits and policies and procedures.
Updated
3 January 2024
About the service
Aspen House is a residential care home providing personal care to up to 22 people. The service provides support to older and younger adults who may also receive care with their mental health. At the time of our inspection there were 22 people using the service, 2 of whom had been temporarily admitted to hospital.
People’s experience of using this service and what we found
Safeguarding systems had not always been operated effectively and safeguarding referrals had not always been made when required. Medicines were not always managed safely. Risks were assessed however, not all risk assessments reflected people's current risks. The principles of the Mental Capacity Act (MCA) had not always been applied to people's care decisions. Managers and staff had been trained but had not always put this training into practice. The provider's governance systems to assess, monitor, improve and reduce risks in the service were not always effectively operated. Statutory notifications had not always been submitted and policies had not always been followed.
People were not supported to have maximum choice and control of their lives and did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
There were enough staff to meet people's needs in a timely manner. Recruitment processes were in place but some required checks had not always been completed. Measures were in place to help prevent and control risks from infection. People were supported to have enough food and drink and the provider worked well with other health and social care professionals involved in people's care. The premises had been adapted to meet people's needs. The service aimed to provide person-centred care to people.
For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk
Last rating and update
The last rating for this service was good (published 24 December 2018). At this inspection we found the provider was in breach of regulations in relation to the safe care of medicines, safeguarding systems, arrangements for assessing people’s capacity for their care decisions and the governance and oversight of the service.
Why we inspected
We carried out an unannounced focused inspection of this service on 14 November 2023.
This report only covers our findings in relation to the key questions safe, effective and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Aspen House Limited on our website at www.cqc.org.uk.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.