Archived: Aspen Court

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this registered service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance.

This service scored 36 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. There had been several managerial changes at the home which had a negative impact on the delivery of care. Many staff and relatives reported the quality of care was much better in the past. One relative said, “We were so happy we’d found somewhere where [person] would be safe, but this has deteriorated in quality over the past few years.” There was a lack of direction for staff, and the team morale was reported as low. One staff told us, “At the minute we are lost as to what we should be doing since there have been that many different managers and strategies."

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. We were advised during the assessment the registered manager in post would not be returning to this home and measures were being put in place whilst a registered manager was recruited. During our site visits, we received negative feedback about the managerial presence within the home. We were informed managers of different skill sets had recently been working at the home to support staff and make improvements, but we found progress to be slow. The home was part of an on-call service where staff would have access to a manager to offer remote support out of office hours, however all staff informed us this system was not effective. One staff member said, “We had a lot of incidents where they have not answered or have not been able to help.” We were also informed daily walk arounds were completed by a manager, but these were not consistent and found the same issues day on day, with minimal action taken to rectify. Following our site visits. a meeting was held with senior managers including the Nominated individual and Chief operating officer who assured us they would take action to support staff.

Staff did feel like they could speak up but did not feel their voice would always be heard. All the staff we spoke with felt confident they would be able to speak up and knew who to contact to do so but did not feel action would always be taken. There was a poster available in the office which included contact details if staff wanted to report concerns anonymously. Staff were also aware if action was not taken when they initially raised the concerns, there were other agencies they could contact. The provider had not sought any feedback from people, staff or relatives about the care and support at Aspen Court.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff had described the team moral to be low as they did not feel supported during challenging incidents as a result of the managerial changes at the home. We received feedback from the Chief operating officer and Nominated individual of how they had introduced specialist staff support at the home since our visits, and the staff team had responded positively to this. We were not made aware of anyone that may have experienced discrimination at the services.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. There had been continuous changes to management within the home impacting on the effectiveness of governance and leadership.The provider had a comprehensive governance framework; however, this was not operated effectively. The providers governance systems and processes continuously failed to assess, monitor, and improve the quality and safety of the service. Overall, audits were not completed regularly, and when completed, they failed to drive improvements.Daily walk arounds and handovers which would have provided the staff team and people in the service with some continuity of safe and effective care, were not completed consistently. We requested the audits of checks carried out by the registered manager; however, we were only provided with records for October 2025. Accidents and incidents were documented; however, information was not clear or detailed. There was no evidence of debrief or follow ups being completed with staff which could have prevented recurrence of incidents happening again. One staff member told us, “I have not been debriefed. It depends what is going on in the office depends on if managers are in. The next day it seems to be forgotten about.” There were no clear systems in place to update rotas following changes which made it extremely difficult to review staffing at the home. Rotas did not reflect who was on the rota versus the actual staff on site, including agency staff. There was a high use of agency care staff at the home who staff did not feel had the correct skill base to be working at Aspen Court. The provider was in the process of reviewing the agency staff at the service. It was also identified during our site visit, staff had not completed relevant training required for their role. This was highlighted with senior managers who took immediate action to address this. There was little progress in completion of actions from audits. Audits had failed to identify concerns and take appropriate action in relation to incident reporting, rotas, staffing, care records, no activity plans and training. There had been no system to gather and then act upon feedback from people in the home and their family members. This meant opportunities to learn from people’s experiences and improve the outcomes for people were being missed. We were advised feedback would be sought by end of this year.

The provider did not understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not share information and learning with partners or collaborate for improvement. We received feedback from professionals on how they had difficulty in obtaining relevant documentation from the service to review. People were under the care of a number of health professionals, but there was poor record keeping on visits which may have taken place.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not actively contribute to safe and effective practice. For example, the provider did not have oversight of how care was delivered. This meant opportunities to analyse and review accidents and incidents for themes and trends did not occur. As a result, improvements to the service and the care people received were not always considered or implemented. There was a lack of action taken following the completion of reviews of events such as accidents and incidents which led to missed opportunities to make improvements to avoid further occurrences. Although there was a service improvement plan in place which identified many of the longstanding concerns, we found during this assessment little action had been taken. On our first site visit we provided feedback to the managers and provider based on our findings. There were some improvements made by our second site visit day.