Aspen Lodge Residential Care Home

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. At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to the governance at the service.

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.

The provider had a shared vision in place however, systems did not consistently ensure the vision for the service was achieved. The vision set out the values and beliefs of the home with an aim of providing a nurturing environment, particularly for those living with dementia. However, the systems in place did not fully support people with dementia, for example changes were needed to the environment and activities on offer. The vision described striving for excellence, however at this inspection we found numerous areas which required improvement, including staff practice and the culture in the home. People told us they did not always enjoy their meals, they were often bored and had little opportunity to go out or follow their interests. People also told us their individual needs and preferences were not always considered when staff provided support. This meant the vision and aspiration for the service was not fully embedded and the culture in the home did not always promote person-centred care.

Leaders did not always demonstrate they had the knowledge and skills to consistently ensure peoples care, treatment and support was effectively delivered. The registered manager did not always ensure systems operated safely and effectively. For example, the provider had introduced CCTV in the home. Where people lacked capacity to consent to the CCTV use, the registered manager had signed consent forms on behalf of those people, which is not inline with the principles of the mental capacity act. The provider had not consistently ensured the systems in place provided people with care which met their needs, managed risks to their safety, and was person-centred. This meant we could not be assured the management team were consistently ensuring safe and effective care and support was received. However, some systems were working well, and the provider had ensured these were monitored. For example, safeguarding systems were working well and there were systems in place to ensure there were sufficient safely recruited and trained staff who felt supported in their role. Notifications were received as required.

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard. There was a policy in place to support and guide staff in speaking up if they were concerned about anything. Staff were all able to describe the action they would take if they were concerned and felt they were not listened to. Staff told us they felt any issues raised to the registered manager would be addressed, but they were all aware of alternative places to raise concerns should this be needed. This meant staff felt confident in raising concerns about people’s safety and understood how to do this effectively.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider information return described how equality and diversity monitoring was completed in their recruitment practice and records we saw supported this. All staff had received training in equality and diversity and there was an equality and diversity policy in place. The policy set out how staffs’ protected characteristics would be considered. Staff told us they felt well supported in their roles and could share examples of how the provider supported them with their individual needs. The provider also gave examples of how they supported individual staff ensuring their protected characteristics were considered. This included how they had developed some cross culture communications plans to support when difficult situations had occurred, and this had been effective in supporting staff.

The provider’s systems for audits and governance were not consistently effective in identifying where things needed to improve and ensuring actions were taken. Medicines audits were in place and completed. However, they had not identified where there were missing as required’ protocols or ensured people had sufficient supply of their medicines. Systems did not check on staff compliance with IPC procedures and safeguarding audits were in place; however, these had not consistently been completed. This meant some systems were either not in place or operating effectively to identify concerns and drive improvements. However, some systems were in place and were working to identify areas of improvement and ensure people received the support they needed. These included the system to ensure staff training remained up to date and the dependency tool in use to determine the level of staff required at the home to support people safely. The provider told us after the inspection they had engaged an external consultant to audit the service and provided us with a copy of the report.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. In the provider information return, the provider told us they worked with a range of partners to provide peoples care and records supported this. The local commissioners collaborated with the provider to monitor the service and provide an action plan. The provider worked to take the required actions and make improvements to the service. The registered manager told us they worked with the west midlands care association and skills for care and attended a local registered management meeting to network and share learning.

The provider did not always focus on continuous learning and improvement. For example, there were missed opportunities to learn about people’s experience of their care during the resident of the day audit. The audit asked staff in the various departments if they had spent time with the person and they indicated yes or no. The audit form did not include any comments made by people about their care and no evidence of how they had been involved in any discussions as part of the audit. forms did not show any comments made about aspects of peoples care by people. However, other systems to learn had been put in place, this included the learning from incidents system which was working to prevent future incidents and ensure learning was shared with staff.