Aspray House

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

At our last assessment in June 2024, we received mixed feedback from relatives about the care provided. At this assessment, we found improvements had been made.

The service had systems in place for investigating incidents, completing accident forms, and analysing trends form an integral part of the service’s commitment to safety and quality. By capturing details, taking immediate action, and reviewing data for patterns, the service was able to respond effectively to incidents and continually enhance its practices.

The registered manager explained that, following the previous assessment, they had re-evaluated their procedures to further improve the service. For example, they had collaborated with staff members to promote openness and honesty within the team, ensuring that everyone was encouraged to remain vigilant regarding any safety concerns.

Staff informed us that the management team held regular meetings with them to review lessons learned and evaluate their knowledge and comprehension of the training provided. A staff member said, “Lessons are shared to improve practice.” Another staff said, “[Lessons learned] is usually done through team meetings, handovers, supervision, training sessions.” A third staff member told us, “We do incident reports and nurses or managers will investigate. We discuss during the daily meetings so staff from other departments will know, and we do supervision so learning can be shared and actions put in place to prevent reoccurrence.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

At our last assessment in June 2024, relatives felt the service was not always proactive in addressing their relative’s health needs. At this assessment, we found improvements had been made.

We observed that the pre-admissions process were completed in full, which demonstrated that the service was able to meet people’s needs. For example, the completed assessment covered people’s requirements, preferences, and potential risks, thereby enabling informed decisions about their suitability for the service.

People’s records indicated that details concerning people’s health were accessible and communicated to healthcare services when required. For example, hospital passport documents summarised people’s health requirements and contained essential information about their medical conditions. We also saw that hospital discharge documents were incorporated into people’s individual care plans to support safe transitions between services.

People and their relatives told us that they were fully involved with the providers pre-admission process. One person shared that they felt happy with the support provided by the staff team at the service, “I have nothing to worrying I’m fine.” A relative told us, “Yes, they usually involve me in discussions, [which has improved]. Another relative said, “I am now more involved in discussions about [my relatives] care.”

Staff told us that the manager had an open communication with staff which helped to, ensure that the person's needs were discussed with the whole staff team. One staff said, “In daily flash meetings and handovers we receive updates from the manager and nurses, which [helps me know what’s happening within the service].”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Since our last assessment in June 2024, we found improvements had been made around how the service safeguarded people.

The home had an up-to-date safeguarding policy and procedure in place, designed to outline the steps people could take if they experienced any form of abuse. A safeguarding log was actively maintained to record details of any incidents, all of which were reported to the local authority for further review.

Where necessary, Deprivation of Liberty Safeguards (DoLS) were implemented and managed appropriately, reflecting best practice and compliance with relevant legislation. This ensured that people's rights and freedoms were respected and protected within the service.

During our visit, we observed clear evidence that staff had successfully completed safeguarding training. Staff were able to demonstrate a clear understanding of the procedures for reporting safeguarding concerns, confidently explaining the steps they would take to ensure the safety and wellbeing of those in their care. Staff comments included, “I would report to the local authority.”Another staff member said, “I would take any concern seriously. Ensure the person is safe. I will report it immediately to my managers. I will inform the next of kin, If needed, I will inform doctor to [complete a health check-up with the persons permission]. I will encourage and support all investigation to protect [the person]. I understand it is my duty as a health care professional to protect vulnerable adults.”

The registered manager told us that ensuring the safety of both the people in their care and the staff team was their highest priority. They expressed trust in the team’s capacity to recognise and respond to safeguarding issues, and that staff frequently undergo assessments to confirm their knowledge of the correct processes for raising concerns with both external bodies and designated internal safeguarding leads.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At our last assessment in June 2024, we identified areas for improvement in regard to people’s risks. At this assessment, we found improvements had been made.

People were provided with personalised risk assessments tailored to the specific care and support they required. These assessments served to identify any potential risks that may impact the person's well-being or safety while receiving care. For instance, we observed that the service had risk assessments in place to assist individuals with diabetes, skin care, and catheter care. These assessments contained comprehensive information tailored to each person’s specific needs, ensuring that the appropriate support was provided.

During our assessment, it was evident that individuals, as well as their relatives, were actively and consistently involved in decisions regarding how best to manage any potential risks. This collaborative approach ensured that people’s preferences and insights were valued, and their voices were integral to the planning and delivery of their care.

One person told us that, “Definitely happy with the care, [I feel safe].”

Staff reported that they were actively involved in the risk assessment process and that daily flash meetings were held by the management team, to discuss any concerns they might have.

A staff member said, “I received risk assessment training, which is mandatory, we are also involved in discussions with the management in different meetings where we can bring any concerns relating to new risks that has been identified”.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Reduce space

During our visit we saw that the service was clean and tidy and the building had been adapted to meet people’s needs. The adaptations appeared to be person-centred, ensuring comfort, accessibility, and safety for all who used the service. Examples of such adaptations included the installation of hoists; mobility aids such as handrails and call bell alarms were fitted in people bedroom and in communal areas.

We looked at the home’s maintenance plan and associated records. The documentation indicated a proactive approach to the upkeep of the property. The service maintained an ongoing schedule of planned works, which helps to ensure that the service remains safe, welcoming, and in good repair. Regular maintenance activities were undertaken, such as safety checks on equipment, repairs to fixtures and fittings, and updates to communal spaces.

The service had a contract with an external contractor, who was responsible for carrying out annual safety checks within the premises. This included gas testing and servicing, electrical checks, and fire safety testing.

We conducted a review of the service's policy and procedures regarding the use of CCTV cameras, which were installed in all communal areas for safety of everyone that used the service. Our findings confirmed that the policy was current and all relevant guidance has been appropriately followed.

We discussed with the management team that there could be a designated room available for staff supervision without CCTV coverage. Which management agreed to consider this suggestion and will review the possibility of implementing such a space.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Since our last assessment in June 2024, we found improvements had been made around staffing levels and support.

Staffing rotas were implemented and clearly indicated the number of staff available to provide care for people. Feedback from people, relatives and staff felt that the staffing levels were adequate to meet people’s needs. Comments included, “Enough staff they are always busy and working hard.” A relative told us, “I feel grateful for the care my relative receives, in the pass there has been a high staff turnover.” Another relative told us, “The carers generally [respond] on time and stay for the duration they are needed.” A third relative told us,” I know most staff including the manager who encourages direct communication. Staffing levels have improved.”

Staff also confirmed that they felt there was enough staff on duty. One staff member said, “Yes in Aspray house, there is enough staff on duty to meet people’s needs”.

The provider had systems in place for conducting pre-employment checks prior to staff taking up their roles. These checks were designed to assess the suitability and trustworthiness of potential employees, with a particular emphasis on protecting vulnerable individuals from harm. For example, staff files were maintained and included application forms, copies of identification documents, references from previous employers, health checks, and criminal records checks. These were crucial in identifying any past convictions or cautions that could pose a risk to the safety and wellbeing of people who used the service.

It was observed that the provider had established effective systems to monitor and ensure that nurses' NMC PINs remained current and were renewed promptly as required. This approach demonstrated a commitment to maintaining professional standards and regulatory compliance within the organisation.

Staff told us they received a full induction programme upon starting at the service. We saw evidence of completed induction forms was available, demonstrating a consistent approach. The induction covered vital areas, including initial training, familiarisation with the service’s policies and procedures, and opportunities for staff to get to know people they would be supporting. One staff member told us, “The induction that I received was very helpful and in depth”.

It was also evident that staff had undertaken training to assist individuals with learning disabilities and those who are autistic, with care pathways tailored to provide support that was individualised, reliable, and adaptable to each person’s needs

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We found the service to be clean and tidy, with domestic staff observed diligently carrying out their duties during the assessment. Toilets and bathrooms were well equipped with appropriate hand hygiene facilities, including paper towels, liquid soap, and foot-operated pedal bins. Hand sanitiser was readily available throughout the home, and posters were prominently displayed to encourage compliance with hand hygiene protocols. The service had a stock of personal protective equipment (PPE) in place for staff to use, such as gloves and aprons.

During the assessment, it was noted that an up-to-date policy on Infection Prevention and Control (IPC) was in place. This policy was readily accessible to all staff members, ensuring that they could refer to the latest guidance and protocols as required.

All staff had received training in IPC procedures. This training equipped them with the necessary knowledge and skills to implement effective infection control measures within the workplace. Regular updates and refresher sessions ensured that staff remained informed about best practices and any changes to the policy.

Staff told us, “I always following infection control procedures, use PPE, and ensure good hand hygiene is completed.” Another staff said, “Good hand hygiene is very important, for example washing hands properly with soap and water or using hand sanitiser before personal and after personal care must be done properly.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

We saw that medicines were being managed safely. We reviewed people’s Medication Administration Records (MAR). The records demonstrated that staff had consistently and accurately completed all entries. Each medicine administered was appropriately documented, reflecting a good standard of record-keeping.

People and their relatives told us that they received their medicines on time, and they were given appropriate support to take their prescribed medicine. One person said, “I get [medicines] on time. Staff come to me with my medicine.”

Records and guidance for topical (such as creams applied to the skin) and when required medicines were in place and up to date.

It was noted that the provider maintained an up-to-date medicines policy, offering staff clear and current guidance whenever needed. This policy promoted the safe and consistent management of medicines throughout the service.

During the assessment, we looked at the procedures and records relating to staff competency in medication management. It was observed that competency assessments were present and appeared to be regularly updated. This indicated a structured approach to ensuring staff remain proficient in the safe handling and administration of medications.