Background to this inspection
Updated
16 February 2024
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.
Inspection team
The inspection team consisted of 3 inspectors and an Expert-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 Manor care home 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 Manor care home is a care home with nursing care, although nursing care was not being provided at the time of our inspection. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
The inspection was unannounced.
What we did before the inspection
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used information we had received about the service and spoke with external agencies, including local authority commissioners, responsible for funding care for some of the people using the service.
During the inspection
During our site inspection visit we spoke with 8 people and 1 relative and observed interactions between people and staff in communal areas. We contacted a further 7 relatives by telephone the day after our inspection visit. We spoke with 9 staff including the registered manager, the deputy manager, the operations manager, team leaders and care staff. We also spoke with a visiting healthcare professional. We reviewed 7 people's care plans and records and reviewed a sample of medicine records. We also reviewed a range of records relating to the day to day management of the service, including 3 staff recruitment files, staff training records, quality assurance and policies and procedures.
Updated
16 February 2024
About the service
Aspen Manor Care Home is a purpose built care home providing nursing and personal care for up to 78 people with a range of needs. Accommodation is provided over three floors and people are able to access various communal areas including lounges, dining rooms and a cinema room. At the time of our inspection, there were 36 people using the service.
People’s experience of using this service and what we found
People did not always have the support they needed to mitigate known risks. For example, records and evidence showed people were not always supported to have enough to drink or to change their position in line with their assessed needs to maintain skin integrity.
People were at risk of poor care and support because governance systems were not effective and needed strengthening. Although audits were taking place they had failed to identify and address the issues we found during our inspection, in relation to poor care monitoring and recording, care planning, medicines and infection prevention and control.
Improvements were needed to ensure people's medicines records were stored and recorded accurately. Improvements were needed to ensure staff consistently followed safe working practices to protect people from the risk of infections.
Staff were safely recruited. Staff did not feel confident contingency plans were implemented effectively to ensure there were always sufficient numbers of staff deployed to meet people's needs.
Improvements were needed to ensure people were fully supported to have maximum choice and control of their lives. Staff supported people in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People, relatives and staff were positive about the registered manager.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 14 June 2023).
Why we inspected
The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risks for people. This inspection examined those risks. You can see what action we have asked the provider to take at the end of this full report.
We undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Aspen Manor Care Home on our website at www.cqc.org.uk.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.