Archived: Aspen Hill Village

Updated 10 June 2022

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.

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

This inspection was carried out by four inspectors, a pharmacist inspector, a specialist advisor and two Experts 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 Hill Village is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Aspen Hill Village is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered manager

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

Before the inspection, we reviewed all the information we held about the service including information about important events which the service is required to tell us about by law. We requested feedback from other stakeholders. These included the local authority safeguarding team, commissioning teams, infection and prevention control team and Healthwatch Leeds. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with nine people using the service and eighteen relatives about their experience of the care provided. We observed care in the communal areas to help us understand the experience of people. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We gathered information from several members of staff including the registered manager, clinical lead, quality manager, medications manager, unit managers, nurses (permanent and agency), care staff (permanent and agency), activity coordinator, business support manager, infection and prevention control lead and trainer.

We reviewed a range of records. This included eight people's care plans, risk assessments and associated information, and other records of care to follow up on specific issues. We also reviewed multiple medication records. We looked at four staff files in relation to recruitment, training, supervision and appraisals. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at quality assurance records, management records and

Updated 10 June 2022

About the service

Aspen Hill Village is a care home that can accommodate up to 180 people who require support with nursing or personal care needs, some of whom were living with dementia. At the time of our inspection, 123 people were living at the service.

The home has six separate units and care was provided in five of the units. Each of the units was providing care to people with varying health and care needs including people living with physical disabilities, people requiring end of life care and people living with dementia.

People’s experience of using this service and what we found

People did not always receive safe care. During this inspection, we identified and reported safeguarding concerns. People's medication was not always administered safely. Risks to people's care were not always managed well or had not been properly identified and acted upon. We found concerns in relation to the safety and management of window restrictors. During our first inspection visit, we identified concerns in relation to risk of cross infection of COVID 19 in one of the units.

People and relatives told us agency staff did not always seem to be knowledgeable about people’s needs or communicated well with people. The provider had developed systems to make sure agency staff were aware of people needs. People told us call bells were not always responded to in a timely way. The provider was not monitoring call bells’ response times; this issue had been highlighted at our last inspection. We made a recommendation in relation to this area.

The provider failed to ensure people's nutritional needs were always met. Several people living at the home had lost weight and some had not been identified before our inspection. Some people living at the service told us the food was not always appetising; this feedback was known to the provider and actions were being taken to address this.

We found staff were offered varied training, but this had not always been completed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies in the service supported this practice. However, we found examples of inconsistent application of the policies. We saw relevant mental capacity assessments and best interest decisions had been completed in several occasions, but we also found examples where this was needed and had not been put in place. We made a recommendation for the provider to review this area.

The provider did not always ensure people received person-centred care and treatment. Some people's care plans were inaccurate and lacked information about people's needs. We found concerns in relation to the provision of people's foot care and lack of evidence around oral care. There were activities happening at the home, but the provision wasn’t always consistent or dementia friendly.

Although people and relatives told us staff were kind and we observed caring interactions between people and staff, our overall findings did not indicate the home was consistently providing a caring service that always respected and was responsive to people's needs.

We found widespread shortfalls in the way the service was managed, in particular a lack of management oversight. There was a risk of people receiving inappropriate care. Quality assurance processes had not always been effective in identifying the issues found at this inspection and in driving improvements. Records were not always accurate and complete.

The registered manager collaborated with the inspection, was receptive to the inspection findings and acted on the issues found or told us the action they would take to address the issues identified.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 18 May 2021).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations and we found new breaches.

Why we inspected

We undertook this inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about safeguarding incidents, management of medication, staffing, infection prevention control and management of the home. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Responsive and Well-led sections of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment, safeguarding, person centred care and good governance at this inspection.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.