Aspray House

On this page

• 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

Staff provided mixed feedback about management. Staff told us they were supported by management, some felt unable to approach managers and did not feel supported. Governance and management of the service was not always robust. There had been several changes to management of the home over the past 12 months. This had an impact on the way the service had been managed. Previous managers had not stayed with the service long enough to bring about and sustain improvements. The current management team are keen to make improvements, and the home manager is in the process of registering to become registered manager.

Lessons learnt meetings and discussions took place and new processes introduced, such as learning following a choking incident. However, improvements were required to ensure learning always took place.

The service worked in partnership with healthcare professionals, however, mixed feedback showed improvements were required.

This service scored 61 (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.

Whilst most staff felt able to speak up, others did not always feel able to do so. A staff member told us, “Staff feel insecure in voicing out their grievances with fear of being sacked, I don’t feel safe and comfortable raising concerns.” Another staff member told us. “I believe that Aspray house offers a secure environment where staff can voice their concerns without worrying about consequences. I am comfortable bringing up any issues and trust that they will be acknowledged and resolved appropriately.”, We made management aware of the mixed feedback from staff and their worries about voicing their concerns.

We saw minutes of meeting which took place, including staff meetings. Staff confirmed they attended meetings and were reminded of their responsibilities during handover or team meetings.

The provider had a whistleblowing and safeguarding policy in place and staff were aware of this. Staff were aware of their role and responsibilities in reporting and acting on abuse, however, some staff did not always feel comfortable to approach management with concerns. The home manager told us they operated an open-door policy where staff could approach them to discuss anything.

The home manager told us they provided flexible working arrangements for staff. For example, a staff member had requested changes to their working hours to avoid them having to give up their job, this was accommodated by the service. Annual leave for another staff member who needed to travel urgently for a period was approved. Staff were provided with a place to pray as part of their religion. During our visit we observed everyone being offered drinks and water as well as ice lollies, including staff and visitors to keep them hydrated during the hot weather.

Staff employed by the service were from diverse backgrounds and different cultures. We made management aware of the use of inappropriate language used when a staff member referred to a person’s ethnicity. The operations manager told us they had reviewed CCTV and felt this had been taken out of context.

We asked management how they would ensure people/staff with protected characteristics were welcomed to the service, for example people from the LGBT+ community. The home manager told us, “We are so culturally diverse in our home I would be surprised if not treated well, people are very respectful. We have our policies. I can’t see that it would make any difference, we include everyone. We have many different religious beliefs, and we are very supportive of this.”

Management told us, staff retention of care staff was good, and the staff turnover was small. Records reviewed showed of the 5 staff files reviewed most had joined the service in 2023.

The home manager told us how they supported staff and had an open-door policy. Staff spoke positively about the home manager who had joined the service in May 2024. Records showed staff had provided some positive feedback to the home manager about how they were supported by them. Equalities and diversity policy and procedures were in place. However, some staff did not always feel able to approach management with concerns.

Governance and management of the service was not always robust. There had been several changes to management of the home over the past 12 months. This had an impact on the way the service had been managed. Previous managers had not stayed with the service long enough to bring about and sustain improvements. For example, the quality of notifications submitted had been poor and staff did not appear to understand their role in submitting notifications. Notifications lacked detail about the incident and actions taken to mitigate risk were not documented.The current home manager had been in post since Mary 2024. During a discussion with the home manager they stated they were still learning and being supported by senior management. This meant the new management and stability of the service required time for this to be embedded. They had applied to become the registered manager, records confirmed this. The deputy operations manager told us they managed the induction process and wanted to ensure they were fit the role a 100 percent. The service understood their responsibilities regarding duty of candour. Systems were in place to monitor the quality of the service, this was not always effective in ensuring areas found during our inspection were closely monitored. During our visit we observed some poor practice in relation to infection control and medicine management. We informed the management team of our findings at the time, and this was addressed. The deputy operations manager provided an overview of the quality assurance process, this included records of monthly announced/unannounced provider visits, weekly managers meetings. Out of hours and night visits were also conducted by the home manager and deputy operations manager. Audits covered, for example, weekly medication and monthly infection control and monthly managers meetings. Records confirmed this.

Staff told us they understood their roles and responsibilities and said they worked well as a team. Care staff knew people very well. Processes were in place to ensure information was obtained regarding people’s needs prior to them being admitted to the service.

Relatives provided feedback on how the service was managed. Feedback was mixed, a relative told us since the change in management communication was not always good. The relative said, previously, “Managers interacted with you and engaged and supported [relative]. You don’t see enough of that now.”

We received mixed feedback from key stakeholders, including health professionals and relatives about how the service worked in partnership with people. A relative who had made complaints said they had met with the home manager but felt there was a lack of resources. They said, “The home manager doesn’t have enough time or support. The home manager is trying but there is no support or resources. This was in contrast with what senior management told us. Senior management told us they provided support to the home manager, who confirmed this. Management conducted frequent visits to the home and were present and on hand to provide support. This includes being at the home 2 days a week, sometimes more. They took a hands-on approach and were on call. This enabled senior management to maintain an overview of what was happening in the service.

Relatives provided mixed feedback on how the service worked with health professionals. Whilst a healthcare professional felt referrals were made in a timely manner, another healthcare professional felt improvements were required. Relatives gave mixed feedback and felt there was sometimes a delay in making referrals to healthcare professionals.

The management team told us they worked in partnership with key stakeholders to ensure people’s health and wellbeing were met. The home was recently visited by 2 local schools who performed a choir service to people using the service. Monthly visits from the local church helped to meet people’s religious/spiritual needs.

Processes were in place to ensure information was obtained regarding people’s needs prior to them being admitted to the service.

We received mixed feedback from healthcare professionals. Whilst there were some areas identified by healthcare professionals as positive, we were also told of some of the difficulties with quality of information and communication. We were not assured people’s healthcare needs were always met in a timely manner.

The service worked in partnership with health professionals, records confirmed referrals were made to, for example, speech and language therapist for people with swallowing difficulties and tissue viability nurse for people with pressure ulcers. A healthcare professional who visited the service once a month told us that monthly multi-disciplinary meetings were held. Attendance included the GP, pharmacist, physiotherapist, dietitian and geriatrician. This helped the service to share knowledge and work with health professionals to assist staff to meet people’s health needs.

Relatives were not always happy with the way the service dealt with their relative’s health needs. Whilst some felt the service was responsive others felt staff did not respond in a timely manner to concerns raised about people’s health needs.

Processes were in place to ensure information was obtained regarding people’s needs prior to them being admitted to the service. Professional partners provided mixed feedback whilst there was positive feedback about the service, other professionals felt communication and provision of information required improvements.

Systems were in place to learn and make improvements to the service. A quality visit from the local authority in May 2024 showed overall they were happy with the service. This was in contrast with some feedback from healthcare professionals which indicated the service required improvement in areas such as staffing levels and providing information in a timely manner. Feedback from relatives also highlighted issues with staffing levels, particularly at night. The home manager told us it is largely about collaborating with each other if something is not working. Flash meetings were held each day, at 10.00am to discuss residents and any concerns or changes to be aware of. The deputy manager told us these meetings went well, they said, “We came up with this in the flash meeting. Something that has worked very well. External visits, they are super well organised, MDT GP visit, work very efficiently.”

The home manager and senior management team reported regular home management meetings were in place to provide oversight of the service. Records confirmed this. Accidents and incidents had been investigated to identify any actions or lessons to be learned. Staff reported their views were now being considered and they were being asked for feedback and potential improvements.

People and staff surveys were taking place to obtain feedback on the service. Resident and relatives’ meetings took place as confirmed by relatives. Relatives confirmed they had been sent a feedback questionnaire asking for their views about the service.