Aspens Cornford Lane

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 provider was in breach of the legal regulation relating to safe care and treatment. This included assessing and mitigating risks and the management of medicines. Risks with regards to nutrition and constipation had not been consistently managed across the service. The provider had not always followed their own policy with regards to the management of medicines. It could not be assured people had received their medicines as prescribed.

People said they felt safe living at the service. However, the environment had not been regularly maintained and decorated. This resulted in some areas not looking inviting due to cracked plaster and damp patches. The home was clean and infection control procedures followed.

Staff had been recruited safely and trained to ensure they had the skills to meet people’s individual needs. Staff used effective strategies to support people who presented as anxious and they knew how to support people to remain calm.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not a consistently positive culture of safety throughout the service. This meant lessons learned had not always been identified to embed good practice.

Staff felt confident to report incidents or accidents and share them with the staff team. These were reviewed by each house manager who could share the information with other relevant parties such as the person’s social worker. However, lessons learnt about best practice in medicines management, assessing potential risks and staff knowledge about safeguarding had not been shared and implemented consistently.

Some people had anxieties which they may present verbally or physically. Staff completed information about the triggers for the behaviour, how the behaviour was displayed and any consequences. The majority of houses employed a positive behavioural support practitioner (PBS) who was supported by the PBS team. PBS isa person-centered approach to understanding and managing challenging behaviours, focusing on preventing them and improving quality of life. Behavioural charts were monitored and reviewed and used to develop and make changes to people’s PBS care plans. For example, one person had specialised, bespoke resources to support them in more appropriate behaviours. Another person was being supported to develop more appropriate ways to communicate their feelings and emotions through the use of pictures. Health care professionals told us that PBS was effectively used at the service to help keep people and staff safe.

There was inconsistency in how the provider worked with people and healthcare partners to help ensure continuity of care, including when people moved between different services.

Hospital passports were in place to support people when they needed to go to hospital or attend clinic appointments. However, some records did not contain all the necessary information for external professionals to know about the person’s health.

There was mixed feedback from health care partners about their working relationship with the service. One health professional told us, “The safety of both the staff and service users are a priority”. Other health professionals told us staff did not always work with them to prioritise peoples’ healthcare as they were not aware of some people’s health care appointments. They said that some appointments had been missed and needed to be rebooked which had led to a delay in people receiving their health checks.

Staff described how they shared information about a person’s communication and health needs with hospital staff. This ensured people had effective support during their hospital stay.

Some people attended the provider’s day service. People’s care plans and risk assessments were shared with them so they knew how to support people in the right way.

There was inconsistent knowledge and practice to fully protect people from potentially restrictive practices and in sharing concerns quickly and appropriately.

Staff had received training in how to recognise and report abuse and their competencies in safeguarding were assessed. There was a safeguarding lead and safeguarding was discussed at team meetings, staff supervision and monthly safeguarding meetings. However, staff knowledge of how to put this training into practice was not consistent across the service. Some staff explained it was practice to investigate a concern internally rather than contact the local authority safeguarding team for advice. Staff did know they could always contact the Care Quality Commission to report concerns and poor practice. We fed this back to the provider to ensure all staff were following safeguarding protocols.

People said they felt safe living at Aspens. One person told us, “Yes, I feel safe here. I have my keyworker. She helps me.” Another person said, “I like my routine. I can get upset if I don’t have my routine, or if people don’t listen to me. I am safe here because I can go to my room: my own space.”

The kitchen door was lockable and when locked people were not able to make a drink or indicate by entering the kitchen they wanted to make a drink. Staff told us the kitchen door was locked for a short period of time, in specific circumstances to keep one person safe. However, this person’s risk assessment did not include the action of locking the kitchen door to keep the person safe. We asked the provider to review this person’s risk assessment and mental capacity assessment to ensure the least restrictive practice was being used to ensure people’s safety. For other potentially restrictive practices such as using lap belts and shower belts, mental capacity assessments had been completed to ensure these measures were the least restrictive.

Some people were subject to deprivations of liberty (DoLS) for their own safety. DoLS applications had been submitted to the appropriate authorising bodies where required. There were systems to monitor deprivations of liberty (DoLS) to ensure people were only deprived of their liberty to receive care and treatment when it was in their best interests and legally authorised under the MCA. There was a record of any conditions in people’s DoLs to ensure they were met.

The provider did not always understand and manage potential risks to people. Staff did not always provide safe care to meet people’s needs.

People’s care and support records contained a number of risk assessments relating to their health and social care. These included encouraging people to pursue their interests, maintain relationships and be a part of their community through positive risk taking. There was detailed guidance about how to support people with any equipment they needed to move around their home and also if people had a seizure. Staff knew how to put this knowledge into practice to keep people safe.

However, there was inconsistency in this best practice across the service. One person was at risk of malnutrition and had been prescribed nutritional supplements to be taken if their weight dropped below a specific weight. This person had not been weighed for six months when their weight was just above this threshold. The manager told us that the person’s relative weighed them, but there was no record of their weight at the service. There was a risk the person would not receive their food supplement when it was needed to maintain a healthy weight.

Risks relating to the management of constipation were not always well managed which put people at risk of harm. People with a learning disability are at significantly higher risk of constipation than the general population. Some people had been prescribed medicines to be given when they had not had a bowel movement for a specific number of days. This included people who were not able to verbalise their discomfort and who had a history of being admitted to hospital with constipation. Two people had not been given their medicines as prescribed. Although these people had not come to any harm there was a risk of potential harm as their medicines prescribed to effectively reduce the risk of constipation were not being administered as prescribed.

Risk assessments did not always contain important guidance for staff on how to support people safely. For a person diagnosed with epilepsy, their bathing risk assessment did not identify they were at risk of having a seizure and could not be left alone whilst bathing. For another person the information about the consistency of their food differed in their care plan notes and risk assessment. There was a potential risk this person would be given food that was not at the right consistency to aid their swallowing.

Each person had a detailed, personalised evacuation plan with clear guidance for staff and emergency services on the support they would need to evacuate the building safely in the event of a fire.

The provider had made sure equipment was safe but had not maintained the environment to an adequate standard to future proof its safety in the long-term.

Essential servicing had taken place such as the maintenance of gas, electricity, fire-fighting equipment and moving and handling equipment. However, the environment had not been maintained to people’s expectations.

All the houses at the service were in need of maintenance, refurbishment and redecoration. This included cracked walls, damp patches, worn carpets and garden patio areas which were not accessible for people who used wheelchairs. One staff member said, “The homes are a bit tired, they all need work”.

The regional manager told us there was a five year rolling maintenance programme. Where work had started and floors had been replaced and rooms decorated this had improved the environment for people. However, there were regular delays in works as the maintenance team were responsible for all the providers services and had been called to other more urgent works at other services.

Health care professionals told us that their professional advice was not always followed when recommending equipment for people to help ensure their safety. They told us when they had recommended beds that lowered to the floor and dining room chairs to reduce the risk of falls, but these recommendations had not been followed.

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 care that met people’s individual needs.

New staff completed a comprehensive induction, including shadowing experienced staff, completing essential training and the care certificate before working on their own. The care certificate are the standards employees working in adult social care need to meet before they can safely work unsupervised.

Staff had undertaken training relating to the wide range of strengths and impairments that people with a learning disability and autistic people may have. Some people had specialist needs such as being fed via a tube that directly feeds into their stomach, dementia or required insulin to be administered. The provider had ensured staff who supported these people had the specific training and skills to meet these people’s complex needs. Staff said the training they had was adequate for their role, and that there were enough staff on duty to provide safe care for the people living at the service.

The staffing levels required for each person were assessed before people moved to the service in partnership with the funding authority. People had shared staffing hours and many people had additional one to one hours in addition to this to meet their needs. Relatives told us there were enough staff available at the service and they had the right skills to support people. People said there were enough staff to enable them to do the things they wanted. They said the only exceptions were if staff were off sick or they attended training courses. People also told us there were staff around at nighttime who they could call if they needed any help or support or could not sleep.

Permanent staff were based at a specific house to help ensure continuity of care. Agency and bank staff could work across houses. The agency coordinator endeavoured to ensure there was as minimal movement as possible for these staff between the houses so they could get to know people and people could get to know them. One relative commented, “My relative needs consistency. They do their best as there’s a good mix of permanent and agency staff, and they are all very professional.”

The provider had undertaken all necessary checks for new staff to ensure safe recruitment decisions. This included obtaining work references, explanations for any gaps in people’s employment history and Disclosure and Barring checks (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had systems and processes in place to assess and manage the risk of infection. There was a structured cleaning schedule with specific tasks allocated to staff members. Relatives told us the service was always clean when they visited.

There was sufficient personal protective equipment (PPE) at each house to provide safe care. Staff had received infection prevention and control training and understood what to do to mitigate infection risks. We observed staff using PPE appropriately throughout people’s homes. The important of PPE practices such as handwashing were discussed at service user meetings to help ensure everyone was involved in maintaining a safe environment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Relatives told us people’s medicines were managed well. However, we found this was not consistent across the service. When people went on social leave, medicines records did not always include the time people left the service, how many medicines they took with them or how many medicines were returned to the service. This included medicines with higher potential for misuse which required special storage and closer monitoring. For one of these medicines, the number of medicines leaving and being returned to the service recorded by staff consistently had not balanced. When we counted the number of medicines in stock there were eight but records stated there were four. This meant staff could not be assured people had been given their medicines as prescribed nor ensure a clear audit trail of medicines.

The service did not always follow its policy for accurate recording of all medicines coming into and leaving the service. One person’s antidepressant medicine had a different dosage recorded on their medication record from what was held in stock. There was a risk staff would give the wrong dosage on this medicine. Records were not always kept of medicines returned to the pharmacy for disposal so there was a clear audit trail of medicines in and out of the service.

Some people had been prescribed medicines to be given when needed due to their anxieties. The directions for staff were to give these medicines when people were

‘anxious’ or ‘agitated’. There was no accompanying guidance for staff about how people presented themselves when they were in these states to ensure the medication was consistently administered when it was needed.