Aspens Cornford Lane

Updated 28 July 2021

The inspection

This was a targeted inspection to check on concerns we had about safeguarding as well as the management and culture of the service.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Three inspectors completed the inspection on-site at Pepenbury. An Expert by Experience contacted relatives of people after the inspection. 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

Pepenbury is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. This means that the provider is legally responsible for how the service is run and for the quality and safety of the care provided. There were several managers allocated to overseeing particular houses who were in the process of registering with CQC for legal responsibility of individual houses.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection and feedback received from partner agencies. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with four people and observed the care people received at two of the houses. We spoke with 10 members of staff including the nominated individual, the regional area manager, quality assurance lead, managers, senior support workers and support workers. The nominated individual is responsible for supervising the management of the service on behalf of the provider

We reviewed a range of records. This included three people’s care records, safeguarding and accident and incident records.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at a variety of records relating to the management of the service, including policies and procedures, quality assurance records and meeting minutes. We spoke with another manager and five relatives of people living at Pepenbury.

Updated 28 July 2021

The inspection took place on 20 September 2018 and was unannounced.

Pepenbury is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Pepenbury accommodates up to 56 people in 8 adapted detached houses. There were 53 people living at Pepenbury at the time of this inspection.

We last inspected Pepenbury in September 2016 when no concerns were found. However, this was the first comprehensive inspection following a change of legal entity and new registration on 5 October 2017.

Each house provides accommodation and personal care for between six and nine people who live with complex learning and or physical disabilities.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with physical and learning disabilities, along with people who also suffer from autism using the service can live as ordinary a life as any citizen.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risks to people's safety had been assessed and actions taken to protect people from the risk of harm. The provider had systems in place to protect people against abuse and harm. The provider had effective policies and procedures that gave staff guidance on how to report abuse. The registered manager had robust systems in place to record and investigate any concerns. Staff were trained to identify the different types of abuse and knew who to report to if they had any concerns.

Each house had been adapted to meet people’s needs and people's rooms had been decorated to reflect their personalities. The premises were well maintained; clean and regular health and safety checks were carried out.

Medicines were managed safely and people had access to their medicines when they needed them. Staff were appropriately trained to provide people with the care and assistance they needed.

Staff met together regularly and felt supported by the management team. Staff were able to meet their line manager on a one to one basis regularly. There were sufficient staff to provide care to people throughout the day and night. When staff were recruited they were subject to checks to ensure they were safe to work at Pepenbury.

Where people did not have the mental capacity to understand or consent to a decision, the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people's ability to make their own decisions had been completed. Where people's liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure each person's rights were protected.

People had enough to eat and drink, and received support from staff where a need had been identified. People's special dietary needs were clearly documented and trained staff ensured these needs were met.

Staff knew the people they cared for well and treated them with kindness, dignity and respect. People could have visitors from relatives and friends at any time.

People and relatives were positive about the care and support they received. People received a person centred experience that enabled them to live active and meaningful lives in the way they wanted. People had freedom of choice at the service. People could decorate their rooms to their own tastes and choose if they wished to participate in any activity.

Staff respected people's decisions. People took part in activities that reflected their choices and interests.

People’s health needs were well managed by staff so that they received the treatment and medicines they needed to ensure they remained healthy.

Staff responded effectively to people's individual needs. Staff interacted with people very positively and people responded well to staff.

The culture of the service was open and person focused. The registered manager provided clear leadership to the staff team.

Audits to monitor the quality of service were effective. They identified actions to improve the service which were followed up and carried out.