Archived: Aspen Court Care Home

Updated 5 January 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 20 September 2017 and was unannounced. The inspection team comprised of two inspectors, a Specialist Professional Advisor and an Expert by Experience. The Specialist Professional Advisor had experience of working and caring for people within health care and managed care services. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. Their area of expertise was in older people living with dementia.

Before the inspection we reviewed all the information we held about the service. This included concerns received about the management of medicines and staffing levels. We reviewed notifications we had received from the provider. A notification is information about important events and the provider is required to send us this by law. We reviewed the provider’s statement of purpose. A statement of purpose is a document which includes the aims and objectives of the service.

We contacted commissioners for social care, responsible for funding some of the people that use the service and Healthwatch Derby and asked for their views. This was used to inform our judgements.

We spoke with 10 people who used the service and five family members who were visiting their relative. We spoke with the regional manager, registered manager, deputy two registered nurses and six care assistants. We also spoke with the chef manager, house-keeper and the activity organiser. We used the Short Observational Framework for Inspection (SOFI), which is a way of observing care to help us understand the experience of people who used the service and we made direct observations of staff’s interaction with people who used the service.

We looked at the records of 10 people, which included their risk assessments, care plans and the daily care records. We looked at a sample of people’s medicine and three people’s medicines records. We also looked at the recruitment records for four members of staff, staff training records, meeting minutes and a range of quality assurance audits and records. We reviewed the information sent to us by the registered manager following our inspection visit.

Updated 5 January 2018

The inspection took place on 20 September 2017 and was unannounced. Aspen Court Care Home provides long term and respite care for adults with a range of physical and nursing needs. This includes palliative and end of life care. The service is registered to accommodate 40 people. At the time of our inspection 38 people were using the service.

The last inspection took place in November 2016 before BUPA (the provider) changed their legal identity to BUPA Care Homes Limited. This was the first inspection of the service since the legal entity changed on 31 January 2017.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission 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.

People did not always receive their prescribed medicines at the right time. We found gaps in the records that showed the systems to manage and store medicines, was not safe.

The provider was mostly meeting their regulatory responsibilities. The provider’s governance system was not used effectively. A range of quality audits were carried out. Shortfalls were not always identified and any improvements made were not always sustained. System to support and manage staff was fragmented. Opportunities to make comment about the service were limited. The registered manager acted on complaints and feedback from surveys. We found the registered manager was responsive and had acted on some of our feedback immediately. That showed they were committed to improving all aspects of Aspen Court Care Home.

People had a choice of food, drinks and snack which were available throughout the day and night. Catering staff were knowledgeable about people’s dietary requirements and planned menus that were nutritious and balanced. Despite this, some people’s nutritional needs were not always met due to inconsistences found in the records used to monitor the nutritional needs.

People had access to a range of health care services but recommendations made by health care professionals were not followed and not always included in the care plans. The registered manager was responsive and took action to ensure people’s health needs were met.

Comments from people, their relatives and staff; and our observations found that staffing levels were not always sufficient to consistently meet the needs of people who used the service. We identified this was an area of improvement as to how staffing levels were determined in the detailed findings within this report.

Staff knew how to keep people safe and understood their responsibility to protect people from the risk of abuse. People’s safety was promoted and protected from avoidable harm. Risks were assessed, managed and reviewed regularly. Measures were put in place including the use of equipment to support people safely and promote their independence.

People lived in a clean environment. Regular checks were carried out on the premises and equipment used in the delivery of care.

Staff recruitment procedures were robust. Staff received appropriate induction and training for their role. Staff felt confident to approach the registered manager when required.

People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People developed positive relationships with the staff. They found staff to be kind and caring. Staff knew people who used the service well and respected their wishes with regards to their care and support needs. People’s dignity and privacy was promoted and maintained by staff. Records showed that people and in some instances, their relatives, had been involved in the development and review of their care plan. This enabled staff to provide care and support that respected people’s preferences.

People mostly received personalised and responsive care when they needed it. Care plans contained information about people’s preferences and how staff should support them to meet their individual needs. Care plans were reviewed regularly.

People maintained contact with family and friends. People’s religious needs were met. People had opportunity to take part in a range of social events, activities and accessed the wider community. This enhanced people’s health and wellbeing and protected them from the risk of social isolation and loneliness.

People knew how to make a complaint and were mostly confident that action would be taken. A complaints process was in place and records showed complaints were handled appropriately. Advocacy information was made available to people.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.