LAM Manor
Derby, DE23 · 0.1 km
Residential
Not yet ratedcare home
CQC report explained · a residential care home, run by Aspen House
Aspen House Limited
33 Carlton Road, Littleover, Derby, DE23 6HB
Requires improvementpublished 3 January 2024, 2 years ago
Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.
The five questions inspectors ask
- Safe?
- Requires improvement
- Safeguarding referrals were not always made, medicines were not always managed safely, and some risk assessments were out of date. Staffing levels were sufficient, and infection control practices were being followed.
- Effective?
- Requires improvement
- The Mental Capacity Act was not always applied to care decisions, and staff did not always put their training into practice. People were supported with food, drink and healthcare, including help from other health professionals.
- Caring?
- Good
- This question was not inspected during this focused inspection. The report says ratings for questions not inspected were carried over from the last inspection.
- Responsive?
- Good
- This question was not inspected during this focused inspection. The report says ratings for questions not inspected were carried over from the last inspection.
- Well-led?
- Requires improvement
- Quality checks did not identify important problems, and statutory notifications and the home's own policies were not always followed. People and staff said managers were available and listened to them.
The latest report, explained
What inspectors found, January 2024
Rated Requires Improvement; inspectors found risks with safeguarding, medicines, consent and management systems.
The inspection was unannounced. One inspector and an expert by experience visited on 14 November 2023. They spoke with 7 people and 6 staff, and checked care plans, medicine records, recruitment files, training records, audits and policies.
The home had enough staff, and people were supported with food, drink, healthcare and infection control. People said staff were helpful and they could choose meals, activities and outings.
However, safeguarding referrals were missed for five people who records showed had been put at risk of harm. Medicines were not always given or recorded safely. Some risks were not kept up to date, and the Mental Capacity Act was not always followed when making decisions for people.
The overall rating fell from Good to Requires Improvement. The home must improve its systems for safeguarding, medicines, consent and checking the quality of care. CQC will request an action plan and continue to monitor progress.
What inspectors praised
Enough staff
Inspectors found enough staff to provide care and support in a timely way.
“We observed staff were available throughout the day to provide people with timely care and support.” from the report
Food and drink
People could choose what to eat, with alternatives available. Their weights and fluid intake were monitored.
“People were supported to eat and drink enough to maintain a balanced diet.” from the report
Healthcare support
The home worked with health professionals and included their advice in people's care plans.
“The provider ensured the service worked effectively within and across organisations to deliver effective care, support and treatment.” from the report
Open culture
People said they felt able to speak with staff and managers. People and staff were involved in meetings and decisions about the home.
“There was a positive and open culture at the service.” from the report
What inspectors were concerned about
Safeguarding referrals
seriousThe home did not always refer incidents to the local authority safeguarding team. Inspectors made referrals for five people during the inspection.
“During our inspection we made safeguarding referrals to the local authority for 5 people where records showed they had been placed at risk of harm and no safeguarding referrals had been made by the provider.” from the report
Medicines safety
seriousSome medicines were given too close together, some as-needed medicines were not fully recorded, and some creams were not applied as prescribed.
“People were not always supported to receive their medicines safely.” from the report
Consent and restrictions
seriousMental capacity assessments and best-interests decisions were not always completed. One person's drink was restricted without the required legal decision-making records.
“The principles of the MCA were not always upheld and applied to people's care.” from the report
Weak quality checks
needs fixingAudits did not identify problems with safeguarding, medicines and consent. Some required statutory notifications and recruitment checks were also missed.
“Systems and processes designed to assess, monitor and improve services and reduce risks were not always operated effectively.” from the report
Out-of-date risk records
needs fixingSome risk assessments did not reflect people's current risks, including a risk linked to smoking while using flammable creams.
“The provider assessed risks to ensure people were safe, however risk assessments had not always clearly identified current risks.” from the report
Questions to ask them, based on this report
- 01What changes have been made to ensure every safeguarding incident is referred to the local authority when required?
- 02How do you now check that medicines are given at the correct times, creams are applied as prescribed, and as-needed medicines are properly recorded?
- 03How are mental capacity assessments and best-interests decisions completed and recorded for people who cannot make particular care decisions?
- 04What new audits or management checks are in place to find problems with safeguarding, medicines and consent?
- 05Have all current risk assessments been reviewed, including risks linked to smoking and flammable creams?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and the report says ratings for uninspected questions were carried over from the last inspection. This explanation was written from the published report of 3 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
The story over the years
Every inspection of Aspen House Limited
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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