Springbank House

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

Systems and processes for monitoring and improving the quality of the service were not always effectively implemented. Risks were not always monitored or mitigated. Systems were not in place to encourage staff to learn lessons when things went wrong. At the time of our on-site assessment the area manager was present and improving the services governance processes. Feedback from partner agencies was mixed. Leaders were approachable and keen to drive improvements of the service to achieve good outcomes for people.

This service scored 21 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff we spoke with understood their role and responsibilities. The management team however could not produce some of the audits and action plans that account for the actions, behaviours and performance of staff and the service. Audits had not been completed since the registered manager left in January 2024. These included a manager weekly walk around audit, an environmental audit, key worker audits and care plan audits. The systems currently in place to manage current and future risks to the quality of the service need to improve. Leaders were open and honest throughout the assessment, they acted promptly on areas that needed to improve following our feedback.

Managers and staff were clear about their roles and responsibilities. The provider and managers were not consistently following their quality assurance systems and processes. Monitoring the quality of the service was not consistent. We found records missing such as incident forms and records missing from staff recruitment files which had not been identified through audit processes. There was an action plan in place identifying areas for improvement, but these had not always been actioned. Following the assessment visits the area manager completed audits and updated the action plan to support improvements they needed to make.

People told us how staff support them when needed to access other organisations. Comments included, "They have tried to be in contact with my social worker as I haven’t seen them since I have been there" and "Staff have helped me contact the doctors I need to see regarding my wishes for my future." Not all people wished to fully engage and give feedback. There was no documentation to support staff seeking advice form partners. We were informed from partners that Springbank had not contacted them for support.

Staff told us they always work with people to give the support they need. However, staff didn’t always feel they got the support they needed from partners. We received mixed feedback from staff about working in partnership with key organisations. A staff member told us, "We support people to access health and social care professional to aid their lifestyle choices.” There was no documentation to support staff seeking advice from partners. A healthcare professional told us, “At [a recent] meeting it became clear that Springbank managers did not understand the functioning of local secondary mental health services and how to access required services for the people who live at Springbank.”

External professionals we spoke with gave us mixed feedback about the provider. One healthcare professional told us they continued to have concerns about, “The lack of staff experience and training to work with people with complex emotional and relational needs.” However, following the first site-visit the provider arranged a meeting with another healthcare professional who told us, “They are definitely moving in the right direction regarding safety planning." Another healthcare professional gave positive feedback about the care a person was receiving at the service. A healthcare professional told us “We remain concerned about the ability of Springbank to meet our client’s needs. As a service we have raised safeguarding’s due to this and have been meeting with adult social care regarding this.”

The provider had processes in place for collecting feedback from partners. Surveys were sent out in December 2023, but no responses had been received.

Staff told us, "We reflect as a team on incidents and accidents. We discuss what went well, what didn’t go well and what we could have done.” However, this wasn’t reflected in any documentation shared during the assessment. Accident and incident reports documented what had happened but did not look at the causes or preventative actions. Incidents such as overdose and self-harming were not cross-referenced back into the care plans or risk assessments.

Lessons were not always learned when things went wrong. During the assessment we identified concerns relating to incident and accident reporting and the management of risks. The area manager told us they were working to establish systems to ensure learning from lessons in the future.