Aspen Lodge Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

During this assessment we looked at 4 quality statements in the key question of safe. The overall rating for this key question combines scoring from quality statements we looked at during this assessment and quality statements scores in line with findings from our last inspection, where the service was rated good. The provider failed to ensure there were robust arrangements to manage risks to people related to maintaining a safe environment. This including risks related to fire safety, security of window restrictors to minimise the risk of people falling from the building and water safety relating to legionnaires' disease. These failings put people at increased risk of coming to harm. This was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. After our assessment site visit we made a referral to Hampshire Fire and Rescue to inform them of the concerns we found around the fire safety arrangements at the service. Staff did not always receive training or training updates appropriate to their role. This included training in key areas such as, safeguarding and specific training in conditions relevant to people living at the service, such as dementia. There was limited evidence that staff’s competence in their role was assessed to gain assurance about their skills and ongoing development needs. The provider had recruited staff safely and in line with requirements. Safeguarding incidents were not always reported and investigated appropriately. Records of incidents and safeguarding alerts demonstrated that concerns were not always followed up appropriately and reported to relevant safeguarding teams or CQC.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We completed observations of staff practice over the 3 assessment site visit days. We observed staff offering care and support to people in communal areas of the home. We found no safeguarding concerns throughout our observations. Staff carried out their duties as expected and people were comfortable and familiar in their presence.

The provider and registered manager’s understanding of implementing practice in line with The Mental Capacity Act 2005 was limited. They were not secure in their knowledge around the need to assess people’s capacity before making application to deprive a person of their liberty to authorising bodies. Staff had a good knowledge about how to identify safeguarding concerns and told us how they would report and record incidents to senior staff.

The provider processes were not always in line with The Mental Capacity Act 2005. For example, there were not always best interests decision records for specific decisions such as, the use of bed rails, alarm sensors and depravation of liberty safeguards. These areas can be restrictive and provider’s need to ensure appropriate processes are followed when considering their use. Safeguarding incidents were not always reported to local safeguarding teams as required. When safeguarding incidents occurred, record keeping did not always reflect that the provider completed analysis or reflective practice to reduce the risk of recurrence.

People told us they felt safe living at the service. Comments included, “I feel safe I am happy here.” People told us they felt comfortable raising issues and concerns with staff. Comments included, “All of the staff are approachable and I have no problems talking to any of them.” Relatives we spoke to told us that they felt their loved ones were safe and settled living at the service. Comments included, “[My relative] is safe here and the whole family feel so much more settled and less worried now [than before living at the service]."

The provider’s risk assessments did not always identify key risks or help to put effective risk reduction measures in place. For example, risks were not fully assessed in relation to the use of bedrails. There was no documentation in relation to checks regarding entrapment and entanglement or assessments to measure of the distances between bedrail and headboard, bedrail and footboard and gaps between bedrail and mattress. This put people at risk as the suitability of this equipment for each individual had not been fully assessed. Risk assessments did not always identify how staff should provide support to manage specific risks or medical conditions. For example, one person had a history of multiple falls, with no evidence their risk assessment had been reviewed or updated after falls occurred. This meant there was limited evidence of analysis to identify trends and reduce the risk of recurrence.

We observed staff providing appropriate support around mobilising and eating and drinking. We observed that staff were attentive when people felt unsettled or anxious and were able to provide support quickly and effectively.

Staff told us they had received training in using mobility equipment when supporting people to mobilise around the home. They told us they felt confident in carrying out these tasks. Staff had a good understanding of risks to people related to their medical conditions, but their knowledge was not always reflected in up to date care planning, care records or care reviews.

People told us that they were supported to manage risks and staff understood how to provide appropriate support around these risks. Comments included, “Staff know I have a swallowing issue and make sure I have a soft diet” and, “My stand aid is there in my room and staff always help me use it."

The provider had not effectively managed risks relating to window safety. On the 1st day of the assessment site visit, we observed that there were a number of windows on the ground and first floor which were not fitted with working window restrictors. This posed a risk to people as it meant the windows could open to a level where people may fall from them. We brought this to the attention of the provider and registered manager, but on the 2nd and 3rd days of the assessment site visit, we observed that there were some windows that had still not been secured. We observed that fire safety equipment was not always in good working order and did not always provide adequate intended fire safety protection. This included fire doors in a poor state of repair with missing intumescent strips and some doors had larger than recommended gaps between the door and door frame. This meant that the fire doors did not always provide protection against smoke spreading in the event of a fire. We observed that fire doors had been wedged open. This meant that there was not adequate compartmentalization in place to help slow the spread of a fire or provide additional protection for people. We observed that there was no fire detection for 2 cupboards containing cleaning chemicals. This posed an increased in the event of a fire as was no means of early fire detection in these void spaces.

People did not raise any concerns about the safety of the environment at the service. This included when they received support from staff using care related equipment. Comments included, “I know my equipment is always there for me to use and staff help me with it."

Legionella checks were not being completed in line with recommendations from an external water safety company. The external company had listed 11 areas which the provider needed to action to reduce risks related to legionella. At the time of the assessment, there was limited evidence these areas had been addressed. Fire safety planning and procedures were not effective in identifying how to keep people safe in the event of a fire. The fire evacuation plan identified people should exit through an external door where a key is required to get out as locked with a padlock, with the key stored in a break glass unit on the wall. However, when we looked the glass was broken and no key was present. This meant that this door was not an effective method of evacuating the building and the provider’s evacuations plan was not effective. People’s personal evacuation plans contained inaccurate information, which meant it was not clear how they would safely be able to evacuate the building in an emergency. In one example, one person’s evacuation plan detailed that they needed one staff member’s support. However, the plan also stated they were to use a piece of evacuation equipment which would need two staff’s assistance to use. Therefore, the correct number of staff had not been planned for. The piece of equipment was also not suitable for use due to the steep and narrow stairs staff would have to navigate to leave the building. Therefore, there was no realistic way staff could carry out an evacuation procedure in line with the evacuation plan. After the inspection site visit, the provider told us the person had been supported to move to a ground floor bedroom after it was acknowledged the previous arrangements were not safe. The provider’s fire safety audits had not identified the issues we found during this assessment around fire safety. They were not effective in reducing the risks associated with fire safety at the service.

Staff told us they received training in fire safety and for the use of care related equipment. The provider told us they had systems to oversee the safety of the environment, including audits and commissioning external companies to complete checks and maintenance work. However, audits were not always effective in identifying issues and recommendations from external companies were not always carried out or integrated into everyday practice. Therefore, the provider’s oversight of the safety of the service was not always comprehensive.

We observed that there were sufficient numbers of staff in place. Staff were utilised in different areas of the home, with some stationed in communal areas, whilst other staff supported people who were receiving care in their bedrooms. We observed a calm and relaxed atmosphere during mealtimes as people and staff interacted naturally in a pleasant dining experience. Staff appeared confident in their role and carried out their duties in an organised and efficient manner.

People told us there were appropriate numbers of staff in place to meet their needs. Comments included, “There is enough staff here to care and support me” and, “There are 3 staff in the day and two at night and management are here as well.” People were positive about staff, telling us they were friendly, attentive and caring.

Staff were positive about their role and told us there was a good working atmosphere at the service. The provider oversaw staff’s training needs and had invested in an external online company to deliver staff training. However, the system to oversee staff’s ongoing training needs was not effective and the registered manager had limited oversight into staff’s compliance with mandatory training. This had resulted in many staff not completing training or updates in their training in line with the provider’s policy.

Not all staff had received appropriate levels of training relevant to their role. For example, a number of staff had not received training or training updates in safeguarding, The Mental Capacity Act 2005, infection control, fire safety and first aid. Staff had not received training around people’s specific medical conditions, such as, diabetes and Parkinson disease, dementia and mental health. Staff did not always receive competency assessments in key areas of their role. This meant the provider could not be assured that staff were working in line with best practice or identify where their ongoing learning and development needs were. The provider had safe staff recruitment processes in place. We reviewed 3 staff recruitment files and found that the provider had completed required recruitment checks to help establish candidates suitability and experience.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.