Springbank House

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

People told us they felt safe living at the service. Staff were aware of their responsibility to safeguard people and how to raise concerns. People lived in a safe and clean environment. People’s individual needs were not always appropriately assessed and addressed in their care plans. The provider immediately addressed the concerns identified. For example, new mental capacity support plans were introduced for every person. Accidents and incidents and other adverse events were not always reported thoroughly, or lessons learnt to reduce risk of recurrence and mitigate risks. Following the first site-visit the provider put in place systems for recording and reviewing incident reporting. People told us they did not always feel there were enough staff to meet their needs. Staff were not always recruited safely.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People using the service told us they felt safe with the care being provided. They felt confident about speaking up if something was wrong. Their comments included, '' I am safe here. If I was worried, I would talk to staff” and “I like it here, sometimes I get angry with things but staff talk with me.” People understood how to raise a safeguarding concern. A person told us, “If I felt anxious or vulnerable, I would talk to a manager or my social worker. I do know I can raise a safeguarding if I felt at risk.”

Staff were aware of their responsibilities to safeguard people from abuse and any discrimination. Staff were aware of the signs of abuse and how to report safeguarding concerns. A staff member said, “We have had training, and we discuss safeguarding procedures at team meetings, the manager updates us of any local changes.” Another staff member said, “We have a safeguarding folder that contains guidance if we need it.” Safeguarding training was up-to date for all staff. A staff member told us “I have had safeguarding training and feel confident that I would recognise any abuse. Then I would definitely raise it through the local authority and inform CQC.”

Throughout the visit staff were vigilant in knowing the whereabouts of people. Observation was difficult due to the nature of people’s mental health, and this was respected.

There was a safeguarding and whistleblowing policy which set out the types of abuse, how to raise concerns and when to refer to the local authority. Mental Capacity Act, safeguarding and serious incident reporting policies were in place. The registered provider must notify us about certain changes, events and incidents that affect their service or the people who use it. Notifications had been submitted and the providers files seen. However, not all notifications submitted where in the appropriate file. Mental Capacity assessments were in place for every care plan but had not been reviewed. Following the first site visit new Mental Capacity support plans had been introduced for every person. All people had been reassessed and records updated. There were systems in place for recording incidents but at the first site visit there were no incident reports on file and no incident log. Audits completed in October 2023 identified missing incident forms and recording improvements needed but these were not evidenced at the fist site visit. Accidents and incidents were not always clearly documented. We found occasions when reports had not been completed. There was no overarching log used to catalogue accidents and incidents, to enable effective oversight, help look for patterns and trends and consider any lessons learned. Following the first site-visit the provider put in place systems for recording and reviewing incident reporting.

People told us they were involved in planning and reviewing their care. Comments included, “I am totally independent. I come and go as I want really. I don’t need any equipment” and “Staff here have been amazing supporting me. I have meetings with my key worker, we talk about what I need.” Not all people wished to fully engage and give feedback.

Staff told us they understood the risks people presented. Comments included, “We monitor behaviours and triggers. If we notice some repeated behaviours, we monitor it closely and record it” and “Risk is managed well, I think. We all read daily logs and add things. We get to know what might be come risky as we get to know the resident.”

We observed people being supervised in the kitchen whilst cooking and at times in the communal areas. On the first day of assessment a person wanted support from staff to go out but there was no staff available. Staff responded when approached by people. We observed people were searching for staff.

Pre-admission assessments were undertaken by the registered manager before people came to live at Springback House. This process was to ensure that the service and staff could meet peoples’ needs. Professional’s involvement in these assessments were viewed and this included previous placements, mental health social workers and GP’s. However, people's care plans did not reflect the reason for admission and did not all contain risk assessments in relation to their identified specific care and support needs. For example, one person who had recently moved in did not have any risk assessments or guidance for staff to follow to support the person with their specific mental health problems. This meant staff did not have the guidance and information to ensure their continued safe care. The care plan and risk assessments for this person were put in to place within 24 hours. For some people with behaviours that may distress, such as self-harming, there was a lack of clear documentation of how staff managed people’s behaviours in a pro-active way. Some people’s behaviours had escalated recently, and these had not been documented within care plans or risk assessments and therefore not managed safely to prevent a re-occurrence. Staff had not recorded all incidents or completed ABC charts to monitor and manage verbal escalations and self-harm. The Antecedent-Behaviour-Consequence (ABC) Model is an approach that can be used to help people examine behaviours, the triggers of those behaviours, and the impact of those behaviours on negative or maladaptive patterns. During the inspection these had been cross referenced within the care documentation and de-escalation plans introduced for each person. The area manager said it had been a beneficial experience for both staff and people and people were fully involved in this process.

People we spoke with told us they liked the home. A person told us “It is pretty nice here. The kitchen is my favourite place.” Another person said “Yes, it’s really clean, we do our own rooms and clean up the kitchen when we cook.” People had personal emergency evacuation plans (PEEPs) which detailed their needs should there be a need to evacuate in an emergency. A person told us “We all talked about fire alarms, and they get tested. There are fire extinguishers in the kitchen.”

Staff told us they were confident they would be able to manage an emergency and talked of the organisational on call systems in place. Staff complete health and safety training and felt confident they follow safe guidance. Most staff had training in ligature risk. However, a staff member told us, “I am not aware of ligature risk, but I am very new still.”

The home was warm and welcoming. The kitchen was well equipped, and all metal cooking objects locked away. We saw people cooking and using the equipment safely overseen by a staff member. The house and garden were safe and well maintained. We observed ligature risks in the lounge which were immediately risk assessed and added to the overarching environmental risk assessment.

People were cared for in an environment that was safe. There were procedures in place for regular maintenance checks of equipment such as emergency lighting, firefighting equipment, hot water outlets were regularly checked to ensure temperatures remained within safe limits. Health and safety checks had been undertaken to ensure safe management of food hygiene, hazardous substances, staff safety and welfare. Systems were in place to manage and monitor the safety of the environment. However, these had not been up-dated regularly. Following the first site visit, a mattress audit was completed for each room and environmental risk assessments updated. At the time of our first site visit there was no environmental risk assessment for ligature risks. Following this visit we were sent new environmental risk assessments for ligature points.

People told us there were not always enough staff to support them. A person told us, “I like the staff they have really helped me.” Another person commented, “There are not enough staff, I don’t get all my 1-1 hours. I wanted staff to come with me to go shopping but there wasn’t any one free”.

The provider told us they had staff vacancies and were currently recruiting a new team. Vacancies were being covered by agency and staff from another of the provider’s service. Comments included, “There are enough staff. We have more staff at present because a person needs 1-1. We can ask for more staff if we need to” and “Mostly we have enough time to give people person-centred care but, we have some agency staff at the moment and so it’s not fluent.”

Staff were not always available to support people. We observed people asking for staff to accompany them shopping but this wasn’t always possible. Staff were observed interacting in a positive way. However, staff were also seen in the offices writing notes and people were knocking on door to see staff.

The provider did not always have safe recruitment practices. We reviewed 10 staff recruitment files. Two staff files were missing references. Following the first site visit, the provider provided missing references for staff. Staff undertook an induction to help make sure they had the skills needed to care for people and keep them safe. However, no induction records had been completed for staff. Staff had not received regular supervision. However, the area manager addressed this following our first site-visit. The rota was not reflective of the actual staff on duty. The provider made immediate amendments. This was checked on the second site visit and was correct. There was no evidence in the care plans of how 1-1 time, as set out by the local authority, was being used and these were explained how it works out -however we have no evidence in the care docs of how 1-1 for improving people’s lives or meeting set goals.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.