Archived: Aspen Court

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.

This is the first assessment for this registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 44 (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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. We reviewed accident and incident reports for the service and found these lacked detail with no debrief or follow up. This meant opportunities for learning were missed. One staff member said, “We are just expected to get on with it.” An analysis was completed of each person’s incident reports and where triggers had been identified, there was little evidence to suggest any action had been taken to mitigate the recurrence of similar incidents. For example, staff had identified the handover process and unfamiliar staff caused anxieties for 1 person, but no action had been taken to mitigate this risk. We also found there was not a consistent approach when people presented behaviours that challenged with staff informing us each staff member will deal with situations differently.

The provider did not always work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. We were informed a person’s own environment no longer met their needs due to a decline in their mobility, even though there was work being completed to look for alternative accommodation, there was no plan in place to meet their needs whilst alternative accommodation was being sought.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. Staff understood their responsibilities in relation to safeguarding and knew how and who to report any concerns to. However staff informed us agency care staff were regularly relied on, but they did not have the correct skill base to work with people who displayed behaviours that challenge, placing the person and themselves at risk of harm. For example, we reviewed incident reports where agency staff had removed themselves from situations where there was a need for 2 staff members to respond safely. We found 1 person had restrictions in place without appropriate legal authorisation to do, this was requested following our visit.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. One person in the service had epilepsy, but we found there was no clear plan in place outlining how staff should access emergency medication when it was stored in a different location. This created a risk staff may not be able to access and administer these medicines promptly during an emergency. The provider took immediate action to rectify this storage issue following our feedback. Incident records identified a failure to follow and implement assessed seizure protocols. We found an instance where emergency medication had been administered later than it should have been, placing people at increased risk of harm. Furthermore, we found no evidence staff had access to people’s emergency medication when supporting people out in the community. CCTV was used in communal areas and was normally monitored from the main office to help staff respond quickly to incidents. However, during our second visit the office was being renovated, and the CCTV was not being monitored. An incident was only identified when we reviewed the CCTV ourselves. No additional arrangements had been made to ensure ongoing monitoring while the office was out of use. During our site visits, it was identified staff were not sufficiently trained to complete the restrictive holds people had been assessed for. Even though we were not made aware of any incidents that resulted in any harm during a restraint, not being effectively trained placed people at risk of harm. Since our site visits, we were informed by managers that appropriate training had been arranged for all the staff. One person at the home was pre-diabetic, and it had been agreed that they wanted support to manage their diet. However, they were not supported to do this, which increased the risk of their condition progressing.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. Whilst some parts of the service were clean, this was not always consistent; we observed other areas which were not clean and were unkempt. Staff did not feel the service met people’s individual needs. One staff member said, “Homes at Aspen Court are not designed for what the service user needs, e.g. you can't walk down the corridors with 2 staff next to [person].” We were also not assured maintenance checks were being completed at the home as records could not be located by managers during our visits.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work well together to provide safe care that met people’s individual needs. Each person had their own funded hours, with some shared hours, however we were not assured people received their funded hours to meet their needs. We found due to staffing issues, some people were left with only 1 staff to support them, when they should have had 2 staff with them at all times. A relative also confirmed they had observed this during their visit. We also found on occasions staff were redeployed from those who did not receive a regulated activity to meet the needs of people who did. There was a high use of agency staff, and staff reported they did not have the correct skill set to work with people at Aspen court. One staff member said, “No agency staff are trained. Not everyone is trained on seizure medication. We ask for staff that have been before, and that they have been trained in challenging behaviours but not a lot of them are.” Another staff member said, “This makes up the numbers but does not provide the right level of care.” Relatives also shared feedback about the poor quality that care agency staff provided to their loved ones. During our assessment we were not provided with any training or induction records for the agency staff, and some of the agency staff who we spoke to informed us they had not received an induction. There were no system in place to accurately record changes made to the rota, and during our site visits we found staff were on site, but these did not match the actual rota. Training compliance levels were lower than 70% for a number of courses, this included administering emergency medication such as buccal midazolam, learning disability training, first aid at work, Mental Capacity Assessment and Deprivation of Liberty Safeguards, diabetes and epilepsy awareness. Staff had also not completed restrictive practice training at the time of our assessment which due to people’s needs was a key requirement for this service. Following our visits, the provider informed us they had made arrangements for this training to be completed as soon as possible. Supervisions with staff were not being consistently completed, with some staff reporting they had not had a supervision for over a year. Following our assessment, we were advised Specialist Support Team members within the provider group were working at Aspen Court to provide staff support and guidance.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Even though, staff had completed Infection Prevention and Control (IPC) training and had access to the providers IPC policy and procedures, cleaning schedules were not always adhered to. Relatives also reported people’s personal spaces and the service vehicle was regularly unclean and unkempt.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. While most medicines were stored appropriately, we found significant concerns regarding medicines awaiting disposal. A large volume of these medicines was not stored safely, meaning the provider could not be assured all items were accounted for. The home did not consistently administer medicines as prescribed. We identified gaps in Medicines Administration Records (MARs), and these omissions were not completed in line with the provider’s policy. As a result, it was unclear why certain medicines had not been given. Although as and when required (PRN) guidance was available for medicines such as pain relief and medication for agitation, some protocols lacked sufficient person-centred detail. For example, where more than one medicine was prescribed for the same symptom, protocols did not always specify which should be used first. For medicines with variable doses, staff did not have clear guidance on when to administer higher or lower doses. The home did not have pain-assessment tools for people unable to communicate, increasing the risk that individuals who were unable to verbalise their needs, may be in pain and might not receive appropriate treatment. In addition, staff did not consistently record the effects of PRN medicines after administration. This made it difficult to determine whether the medicines had been effective or not. We could not be assured that all staff involved in handling or administering medicines had received up-to-date training or had undergone annual competency assessments. This meant we could not be confident staff were trained and competent to administer these medicines safely. Although regular medicines checks were completed, the issues identified during our visit had not been identified. This demonstrated existing processes were not effective in identifying areas of risk or areas in need of improvement.