Aspens Cornford Lane

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 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 provider was in breach of legal regulation in relation to the governance of the service. New quality assurance processes had been developed but they were not always effective in identifying shortfalls. This meant issues were not always acted on to make the necessary improvements. There were differences in staff culture across the service and this was acknowledged by health care professionals feedback.

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.

The provider had a shared vision, strategy and culture but this had not been consistently disseminated throughout the service.

Staff culture had been identified as an area that needed improvement in the last staff survey in 2024. The chief executive office told us they were working on the culture of the service and how to support staff. We found this was a work in progress. There was a culture where there was limited communication between some of the houses which may have led to different cultures developing. There were variations between houses in how well staff felt supported and motivated to meet the aims of the service in ensuring people lived a fulfilling life.

The provider had structures in place to acknowledge staff’s achievements and aid communication between staff in the individual houses. Staff were nominated for employee of the month and given a certificate to acknowledge their achievements. Staff were kept up to date with what was going on with the company via weekly newsletters. Staff had also attended a conference held by the provider for training and communication.

There was inconsistent practice in how leaders embodied the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge and experience to lead effectively.

Each house had a designated manager, some of whom were also responsible for other of the providers services so divided their time between them. Managers were supported by senior staff. Feedback from external professionals was that managers were not always easy to contact and had not always responded to request for information.

The provider had a quality compliance team who monitored the delivery of care and support and created action plans where improvements were needed. However, this process and support had not always led to necessary improvements as highlighted in this report. The managers of each house met together for regular management meetings but there was no specific agenda or recorded actions from these meetings.

Managers kept up to date with best practice by completing training, reviewing information from CQC and attending meetings held by the provider and health and social care organisations.

There was inconsistency in staff confidence in speaking up and that their voice would be heard.

Staff were invited to regular staff meetings where discussions took place about peoples’ well-being and the well-being of staff. There were variations in how involved staff were in these discussions and how their voice was heard. Some staff were really positive about the management team. They said they were always available, supportive and quickly responded to any concerns they may have. However, this view was not consistent across the service. Some staff did not feel confident to follow the provider’s whistle-blowing policy. This is that if a staff member raises a concern about poor practice that they are protected from being victimised as a result of what they have raised with the provider.

The provider valued diversity in their workforce. They worked towards improving equality and equity for people who worked for them.

The provider had policies in place to guide staff to make sure equality and diversity were considered in all aspects of their work. This included ensuring recruitment processes did not disadvantage different groups of people. Staff had received training in equality and diversity and knew how to put this into practice.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The service had three registered managers who were responsible for overseeing the service. These registered managers were spread across the different houses to enable them to have more detailed knowledge of specific houses. Some of them also had responsibilities for other services across Kent and Sussex. The managers met together but these were informal chats as there was no agenda nor any actions at the end of the meeting. We received mixed feedback about how effective these meetings were in ensuring registered managers had oversight of the whole service.

The programme of audits included staff, manager, peer and external reviews by their quality team. However, they had not always been effective to identify shortfalls and monitoring the quality of service provision. Nor had they ensured consistency in best practice across the service.

There was a lack of understanding of how to complete audits which meant they were not effective in highlighting shortfalls for improvements to be made. A property inspection audit of one house in October 2024 had rated the service as having good and outstanding elements. However, this house had not been maintained to a good standard as it needed new flooring and redecoration due to general wear and tear. The regional manager said it appeared the auditor had ticked each question to say they had inspected the aspect of the property but not if any actions were needed to ensure it was maintained to an appropriate standard. On an infection control audit for February 2025 it had been highlighted that bedroom curtains did not meet the required standard. There was no description of the reason for this or if any action needed to be taken. The registered manager was not able to explain this decision by the auditor or what it meant.

Where improvements had been identified, they had not always been addressed in a timely manner. Timescales for actions continued to be extended when necessary improvements had failed to be completed. The action plan for one house was to ensure health care appointments were booked for each person including dentist and optician. This remained uncompleted 7 months later. The provider confirmed health care appointments had been booked for these people during this assessment. At other houses there were actions to complete maintenance tasks such as replacing carpets. These actions had continuously been carried over from month to month without being completed.

The provider was not aware the health and safety audit did not cover all aspects of fire safety. Although staff told us they were regularly testing the fire alarm at different call points to ensure it was in good working order, there was no record of these actions. Therefore, it could not be assured all staff were carrying out these ongoing fire maintenance checks.

We identified shortfalls in assessing people’s mental capacity, risk assessment and medicines management which had not been identified by the provider’s quality checks.

Good practice had not always been shared amongst the service which resulted in inconsistent practices across the site. For example, some houses had regular audits of medicines where shortfalls had been highlighted and appropriate actions taken to make the necessary improvements. However, some houses did not have regular audits nor they had been effective in highlighting concerns with medicines identified in this report.

The provider did not always fulfil their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider had systems and processes in place to collaborate and work in partnership with health partners, social services and the local authority contracting teams. There was inconsistent practice in how effective this was across the service. We received mixed responses from external professionals. Some were positive about the working relationships but others told us senior staff could be reluctant to engage positively in suggested interventions. This enabled them to share information and learning with partners and collaborate for improvement.

The service had originally been developed as a village community for people with a learning disability. The model of care had been developed to help ensure people went out to activities away from the village and that local people visited the village. This was to ensure people were fully involved in community life. The chief executive officer told us, “We are trying to make the site a destination and a space the community enjoys and wants to spend time in.” There was a café, plant nursery and animal barn which were open to members of the public to visit.

The provider’s approach to continuous learning, innovation and improvement was not always effective across the organisation.

Although the provider had sought feedback from relatives and staff about things that were working well and where improvements were needed, this been had undertaken across all services in Kent and Sussex. The provider was not able to drill down to the service as a whole nor each specific house to identify where highlighted issues were most prevalent. For example, themes had been identified that staff needed more support to meet the aims of the service and have clearer career progression. However, this action could not be targeted at a specific service or individual houses to make the necessary improvements as these had not been identified in the feedback. The provider had recognised this shortfall and told us that the next surveys would ask staff and relatives which service they were feeding back about.

Feedback from health and social care professionals was mixed in staff’s approach to making improvements. One health professional told us, “The standards of care can vary across the houses but generally I see positive outcomes from health care appointments”. Another professional said, “Staff can be reluctant to take on professional ideas and health care resources”.