We carried out a review of the data available to us about Aspens Cornford Lane on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Aspens Cornford Lane, you can give feedback on this service.
Pepenbury is a residential care home providing accommodation and personal care for up to 56 people who live with complex learning and or physical disabilities or autism. Pepenbury was accommodating people across seven adapted houses which can house between six and nine people each. At the time of the inspection there were 50 people living within Pepenbury.
People’s experience of using this service and what we found
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports the Care Quality Commission (CQC) to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.
This was a targeted inspection that considered the safety and management of the service. Based on our inspection of safeguarding, people's care and the management, the staff were able to demonstrate how they were meeting the underpinning principles of right support, right care, right culture in their care delivery. Each house was operating independently of the other houses.
Right support:
• Model of care and setting maximises people’s choice, control and independence for example, people were supported to do activities within the site location as well as in the wider community.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Right care:
• Care is person-centred and promotes people’s dignity, privacy and human rights. People were supported by staff who understood their individual differences in a respectful manner.
Right culture:
• Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives. People’s views were sought by staff and the management, these were listened to and acted on to achieve good outcomes for people.
Regulatory requirements had not always been met by the provider. We discussed the requirement to notify CQC and to raise safeguarding concerns with the local authority. The nominated individual was aware of these shortfalls and had introduced new processes and guidance to ensure the shortfalls did not happen again in the future.
Despite concerns that had been raised, we found that people were being supported safely by staff who knew them well. People told us they liked living in their houses. Staff were aware of signs that might indicate potential abuse, where there were any concerns about a person’s well-being this was recorded and reported to management. Changes were made to ensure concerns were addressed and risks were mitigated.
Risks to people and their needs had been assessed and reviewed whenever there were changes. Staff knew how best to support each individual in a person-centred way and followed the guidance in place in people’s support plans.
The culture within the service was open and caring. Staff from all levels reported they felt supported by their seniors. The provider had quality assurance processes in place to drive improvements and monitor the quality of care.
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 (27 November 2018).
Why we inspected
The inspection was prompted due to concerns received about the safety and management of the service. A decision was made for us to inspect and examine those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We have found evidence that the provider needs to make improvements in relation to reporting safeguarding incidents to the relevant local authorities and the Care Quality Commission. However, the provider was already aware of this and had developed and implemented new processes to address this. The issues with reporting had no impact on the safety of the people living at Pepenbury. Please see the well-led section of this full report.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Pepenbury is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Pepenbury accommodates up to 56 people in 8 adapted detached houses. There were 53 people living at Pepenbury at the time of this inspection.
We last inspected Pepenbury in September 2016 when no concerns were found. However, this was the first comprehensive inspection following a change of legal entity and new registration on 5 October 2017.
Each house provides accommodation and personal care for between six and nine people who live with complex learning and or physical disabilities.
The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with physical and learning disabilities, along with people who also suffer from autism using the service can live as ordinary a life as any citizen.
The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Risks to people's safety had been assessed and actions taken to protect people from the risk of harm. The provider had systems in place to protect people against abuse and harm. The provider had effective policies and procedures that gave staff guidance on how to report abuse. The registered manager had robust systems in place to record and investigate any concerns. Staff were trained to identify the different types of abuse and knew who to report to if they had any concerns.
Each house had been adapted to meet people’s needs and people's rooms had been decorated to reflect their personalities. The premises were well maintained; clean and regular health and safety checks were carried out.
Medicines were managed safely and people had access to their medicines when they needed them. Staff were appropriately trained to provide people with the care and assistance they needed.
Staff met together regularly and felt supported by the management team. Staff were able to meet their line manager on a one to one basis regularly. There were sufficient staff to provide care to people throughout the day and night. When staff were recruited they were subject to checks to ensure they were safe to work at Pepenbury.
Where people did not have the mental capacity to understand or consent to a decision, the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people's ability to make their own decisions had been completed. Where people's liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure each person's rights were protected.
People had enough to eat and drink, and received support from staff where a need had been identified. People's special dietary needs were clearly documented and trained staff ensured these needs were met.
Staff knew the people they cared for well and treated them with kindness, dignity and respect. People could have visitors from relatives and friends at any time.
People and relatives were positive about the care and support they received. People received a person centred experience that enabled them to live active and meaningful lives in the way they wanted. People had freedom of choice at the service. People could decorate their rooms to their own tastes and choose if they wished to participate in any activity.
Staff respected people's decisions. People took part in activities that reflected their choices and interests.
People’s health needs were well managed by staff so that they received the treatment and medicines they needed to ensure they remained healthy.
Staff responded effectively to people's individual needs. Staff interacted with people very positively and people responded well to staff.
The culture of the service was open and person focused. The registered manager provided clear leadership to the staff team.
Audits to monitor the quality of service were effective. They identified actions to improve the service which were followed up and carried out.