Aspen Lodge Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The provider did not have effective or robust governance systems in place to monitor and improve the quality of care and safety of the service. The provider did not always act on recommendations of professionals to make changes where improvements needed were identified. The provider had not always reported significant incidents to local safeguarding teams or CQC as required.

This service scored 62 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager and provider did not have a robust overview of the quality and safety of the service. They were responsive to our feedback during the assessment but did not always demonstrate they were able to put effective action in place in response to concerns raised. For example, on day 1 of our assessment site visit, we requested immediate assurances in relation to missing and faulty window restrictors throughout the service. On day 2, the provider informed us that an external company had been contacted to fix the window restrictors. However, there were no interim safety measures in place to rectify the issues, such as locking the windows. The provider and registered manager were not aware that the window restrictors in place are not suitable in health and social care premises where people are identified as being vulnerable to the risk of falls from windows. We requested the registered manager do a full walk around to determine which windows were affected, carry out a risk assessment and put measures in place to minimise the risks. On day 3 whilst some windows were locked, we found some that were still not secure.

Processes to oversee the quality and safety of the service were not robust. For example, provider audits around fire safety did not identify issues relating to fire detection, fire doors and fire evacuation arrangements. The provider carried out a review of the service’s fire risk assessment. However, they were unable to provide us sufficient assurances that they had undergone appropriate training to the required level of competence to carry out such a review. The provider did not always act upon recommendations from external professionals to improve the safety of the service. For example, The Fire and Rescue service made recommendations regarding the fire panel, during a visit in August 2023. However, the provider had failed to take action in response, which meant that fire safety arrangements were not always in line with recommended standards. The provider’s audits around water safety, window restrictors, care planning and risk assessment were not effective in identifying issues and putting measures in place to improve the quality and safety of the service. The provider did not have effective systems to ensure all notifiable incidents were reported to professional bodies such as local safeguarding teams and CQC. We highlighted 3 incidents which met the threshold for statutory notification to CQC, which the provider agreed to submit retrospectively.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.