Aspen Lodge Residential Care Home

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 good. At this assessment, the rating has changed to 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 relating to infection prevention control practices.

This service scored 56 (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’s systems to learn when things went wrong were inconsistent. When incidents were investigated as a complaint or raised as a safeguarding there was no evidence shared to show a wider analysis of incidents at the service was taking place to enable patterns and themes to be identified and acted upon. This meant there were some missed opportunities to learn and make improvements. However, where individual incidents and accidents occurred records showed these had been investigated and action was taken to improve individual people’s safety. For example, when a person experienced a fall, a referral to a doctor, an occupational therapist and changes to the person’s care plan had been made and shared with staff. The registered manager told us learning from individual incidents was shared with staff during team meetings and daily flash meetings, along with during the resident of the day audits and in staff supervision. Staff confirmed they had information shared with them if people had an incident. For example, if someone had a fall this would be discussed at handovers, in team meetings and any changes to the person’s care would be highlighted for staff.

The provider’s systems were not used in a consistent way to maintain safety. The provider had developed systems to ensure people were safe, however these were not consistently applied. For example, there was a system in place to ensure people had repeat prescriptions ordered in a timely manner to ensure delivery before the medicines stock ran low. However, this had not been consistently effective, and people had gone without their medicines. We found no evidence to show people had come to harm because of this, but this system not being effective placed people at risk of harm. The registered manager told us that care plans and risk assessments were to be reviewed monthly and updated, however records did not show this had been completed consistently. The electronic records system was in place to record when people had their care delivered, however some people’s care records showed gaps in care which did not match the care that staff told us people had received. This meant the provider could not be assured the systems in place were keeping people safe.

The provider collaborated 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. People told us they felt safe living at the service. A person told us, “I’m very safe here because everything is to hand. If I want something they get it for me. If I need a drink, they get me one.” Staff had received training in safeguarding and were aware of the signs of abuse and how to report any concerns they may have about people. The registered manager ensured any incidents of potential abuse were reported to the safeguarding authority for investigation. When incidents were raised with the provider by the safeguarding team they responded appropriately. This meant people were safeguarded from abuse.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the provider had a system in place to ensure applications were submitted to the authorising body as required and tracking was in place to ensure any conditions were met and renewals were requested.

The provider’s systems were not consistently used to monitor risks to people’s safety. People told us they felt staff supported them to manage risks to their safety. A person told us, “I can’t walk now, I use a hoist and wheelchair to get around. It’s awkward but I feel safe. It has to be 2 staff, and it always is.” Staff were knowledgeable about people’s risks and people told us they were supported to manage risks to their safety. However, improvements were needed to the detail in people’s risk assessments and care plans to guide staff on managing risks to people’s safety. For example, 1 person had a continence care plan and catheter risk assessment in place regarding a urinary catheter. There was no guidance on how frequently to empty the catheter or how to monitor urine output. We looked at the person’s catheter chart and staff had not consistently recorded the persons urine output and there was inconsistency in how frequently this was checked by staff and the amount of urine passed. This meant we could not be assured risks to the person were managed safely as the care plan lacked detail and records were incomplete. Other risks were documented clearly. For example, where a person had diabetes there was a detailed risk assessment and care plan in place and staff had completed comprehensive records which showed interventions and monitoring. This meant we could not be assured all risks to people were managed effectively.

The provider’s systems did not always ensure potential risks in the care environment were managed. The provider had fitted locks to some communal rooms to minimise the risk of people entering some areas of the building to maintain people’s safety. However, during the inspection we identified 2 of these doors had been left unlocked. The registered manager was informed about the doors being unlocked and confirmed they would address this with staff. Staff told us they understood how to report any concerns about the environment. The registered manager told us there was a system in place for any repairs to be reported and maintenance staff were employed to address any concerns. On the day of the inspection, we found some concerns which had not been reported by staff, meaning the system in place was not always effective. There was faulty lighting in a corridor, a radiator cover was loose in a corridor and a wooden rail had come away from the wall in a lounge area. We raised these with the registered manager, and they sourced a prompt repair during the day of the inspection.

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. People had mixed views about if there was enough staff. Most people told us they felt there were enough staff to support them when they needed help and they didn’t have to wait too long, but some felt they did not always get a prompt response. Staff told us they felt there were enough staff to support people safely. The registered manager told us they had a system in place to determine how many staff they needed to support people safely. The provider had a recruitment policy in place to ensure staff were recruited safely. Staff told us they had checks in place before they commenced working at the service and records we saw supported this. Staff told us they received training to support them in their role. The registered manager told us this was monitored to ensure staff had access to refresher courses and records we saw confirmed this. Staff told us they had regular supervision sessions and could access support in their role. We saw staff had opportunities to discuss their role with the registered manager on a regular basis.

The provider’s systems did not consistently ensure the risks associated with cross infection were minimised. During the inspection our we saw staff were not consistently following the procedures in place to minimise the risk of cross infection. For example, a staff member was observed placing used gloves into a wastepaper bin instead of using the clinical waste disposal system in place. In another example, a staff member was observed not to use hand gel or wash their hands when removing protective equipment. This placed staff and people at an increased risk of cross infection. We spoke to the registered manager about this, and they confirmed they would speak with staff about this and take the appropriate action. However, the provider had an infection prevention control policy in place and staff had received training courses to support them in implementing safe infection prevention control practices. This included training in the use of protective equipment and hand hygiene. The registered manager undertook audits and observations to monitor infection prevention control. The Provider’s Information Return (PIR) referenced regular input from local infection prevention specialist teams and an audit had given them a gold standard. The PIR is an annual submission that requires providers to share information with is about the service.

Medicines administration guidance and records were not consistently in place and people were not consistently supported to take their medicines in their preferred way. People had mixed views about the support they received to take their medicines. A person told us, “They bring me my medicine every day. When I want pain relief I ask for it and I get it.” Whilst another person told us, their medicines were given even when they said they were not ready for them. We found some ‘as required’ medicines did not have the required protocols in place. We spoke to staff about this, and they were aware these were required but could not tell us why they were not in place. Records showed that some people had missed medicines due to the system in place for requesting replacement medicines not being consistently effective. However, staff had taken appropriate action in response to these missed medicines to ensure people had their health needs checked, and the relevant health professionals were informed so people could be closely monitored. Medicines were stored safely, and medicine administration records were accurately completed, and staff had received training and had their competency checked.