Spring Lake

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

The rating has improved from requires improvement to good during this assessment. Risks to people's safety and wellbeing had been assessed and planned for. People lived in a safe environment. Systems were in place to investigate accidents, incidents, complaints, and safeguarding incidents. Staff and the manager communicated and worked with other agencies to help keep people safe. There were systems to help prevent and control infection. People’s medicines were managed safely and they received these as prescribed. There were effective systems in place to safely recruit staff. There were enough staff to care for people. Staff were well trained and supported.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Family members knew how to make a complaint and said that they wouldn’t hesitate to raise concerns with management. A family member said, “I have confidence that they [the manager] will take action and address any issues.” Family members said they were confident the manager would respond to concerns and make necessary improvements. People had monthly reviews with their allocated key worker so that they had an opportunity to communicate their concerns if they had any.

Staff explained that the manager and their colleagues helped them learn and improve practice when things went wrong. For example; lessons learnt were discussed in staff meetings and daily handovers. The manager told us they investigated adverse events and had learnt from these. They gave an example of improvements they had made around consistently reviewing forms of restrictions placed on people in the home. This had involved communication with family members and staff to ensure that restrictions were not unduly excessive.

Processes were in place for investigating, analysing, and responding to accidents, incidents, complaints, and safeguarding alerts. We noted that accident/incident forms included details of the action taken following an accident/incident but there was a lack of documented detail around lessons learnt. We raised this with the manager who said that they would amend the form to include this but stressed that lessons learnt were always discussed with staff. Following a monitoring visit by the local authority, the manager had used learning from this and feedback from stakeholders to help create an improvement action plan. They shared this learning with staff to help make sure changes were embedded in the home. Team meeting minutes showed staff had an opportunity for reflection on how to improve the running of the home.

Family members told us they were informed and involved in people’s care and support planning.

The manager shared some examples of referrals made to the local authority. Risks to people’s health had been identified. Clear communication had taken place between the manager and other care professionals.

There was evidence from the provider that they worked well with the local authority. The referral and transition process was effective.

The provider worked closely with other care professionals and the local authority. There was a referral and admission process in place. This meant people could feel confident they would receive joined up care.

Family members told us they were confident people were safe in the home. A family member told us, “[My family member] is safe in the home. It is a safe place.” Another family member said, “I am confident [my family member] is safe in the home and around staff.” Family members we spoke with did not raise any concerns about people’s safety in the home.

Staff we spoke with felt confident reporting concerns. They were able to describe the action they would take if they witnessed or suspected any abusive or neglectful practice. The manager was aware of their responsibilities on how to help protect people from abuse and the actions they would take where there was an allegation of abuse.

We observed people were safe in the home.

There were suitable procedures for safeguarding people. These provided guidance about the action to take if staff had concerns about the welfare of people. Training records showed staff had completed safeguarding training. There was a system in place for recording safeguarding concerns which helped management have oversight over this. The manager had appropriately made safeguarding referrals to the local authority.

Family members we spoke with felt risks were well managed in the home. A family member said, “They manage risks well in the home. It is a balance.” Another family member told us, “They assess risk and make sure people are safe.”

Staff assessed risks to people's health and safety. Staff were able to describe how they supported people safely to reduce the risk of harm. Staff were encouraged and supported to report risks so that appropriate action could be taken to help ensure the safety of people. Staff we spoke with told us they wouldn’t hesitate to raise concerns with management and had confidence that the appropriate action would be taken. Staff had received training to understand how to de-escalate situations when people became agitated.

We observed people were supported and cared for in a safe way. We saw staff explained what they were doing, encouraged people to make choices in their preferred communication method and did not rush them.

Risks to people's safety and wellbeing had been assessed. Risk assessments included detail about how they could support people and reduce risks. These included personalised information and had been regularly updated and reviewed. Risk assessments covered various areas such as the environment, transfers and medical conditions. They were person centred and included information about the level of risk and how to minimise the associated risk. Staff received training in areas of potential risk such as moving and handling, first aid and health and safety. Personal Emergency Evacuation Plans (PEEPS) had been completed for each person. PEEPS give staff or the emergency services detailed instructions about the level of support a person would require in an emergency such as a fire evacuation.

People lived in a safe environment. People’s rooms were personalised. The lighting, ventilation and temperature were appropriate and met people's needs. Family members we spoke with did not raise any concerns about the environment.

Staff told us they knew how to ensure the environment was safe. Management and staff carried out regular checks on equipment and safety. The manager told us some areas of the home were due to be renovated and there were plans to do this in September 2024.

There was enough suitable furniture and equipment to meet people's needs and to ensure they were comfortable. The environment was free from clutter or hazards. People had their own bedrooms which were light, personalised and well equipped. There was a spacious and welcoming garden. However, some communal areas of the home looked tired and in need of renovation.

Processes were in place to ensure risks within the environment were assessed and monitored. There were regular checks and a maintenance system to help ensure the home remained a safe place to live. Regular checks on appliances and equipment and checks on safety items such as window restrictors were carried out. Fire drills and regular fire alarm tests had been carried out and were recorded appropriately. The manager explained that since the last inspection, they had fitted thermostatic mixing valves (TMVs) on all hot water outlets to ensure that the temperature did not exceed 43ºC. Staff carried out water temperature checks prior to providing personal care to people. Each person had a hot water risk assessment in place. However, we noted that these lacked detail about what water temperature people preferred. We raised this with the manager who advised that this detail would be added.

Family members were complimentary about care staff. A family member said, “Staff are very kind and polite. They look after [my family member] well.” People received support from the same team of care staff. They experienced continuity of care. A stable and regular workforce helped people feel comfortable around care staff and support them to develop positive relationships.

Staff told us there were sufficient numbers of staff to safely meet people’s needs. Staff spoke positively about staffing numbers. They said that if staff were off work, appropriate cover was arranged. A member of staff told us, “There are enough staff. We can meet people’s needs with the number of staff on duty.” Staff spoke positively about communication in the home and said they were kept informed of any changes and developments in the home.

Staff were attentive and responsive when people needed care and support. On the day of our site visit, we observed that there were sufficient staffing numbers and staff were not rushed. Staff were able to spend time interacting with people.

Policies and procedures were in place to help ensure staff recruited were assessed as safe to work with people. Checks on the suitability of potential staff were completed. This included obtaining references and checks with the Disclosure and Barring Service (DBS). The DBS helps employers make safer recruitment decisions and help prevent unsuitable people from working in care services. We were assured that there were sufficient staff to meet people’s needs. The staffing rota indicated that there were sufficient permanent staff working at the service to cover planned and unplanned staff absences. People were supported by staff who had the knowledge and skills required to effectively meet their needs. Records showed that staff had received training in areas relevant to their roles. Staff received supervision sessions which provided an opportunity for them to discuss their performance and professional development.

Family members told us the environment was kept clean and staff followed good hygiene practices, such as hand washing and wearing protective clothing when needed. A family member told us, “The home is always clean. Always.” Another family member said, “The home is clean. When I visit it is always clean.”

Staff completed training about infection prevention and control. They were given the information and guidance they needed. Staff we spoke with were confident about what their responsibilities were in relation to infection control.

The environment was clean and free from clutter. On the day of the assessment, we saw cleaning staff clean communal areas in the home.

There were procedures for managing and preventing infections. Staff and the manager carried out regular audits of cleanliness. The manager explained that a designated cleaner was responsible for cleaning the home 3 times a week and the other days care staff managed this.

Family members told us people received the support they needed with their medicines. They did not raise concerns about the medicines support people received. People’s behaviour was not controlled by excessive and inappropriate use of medicines.

Staff spoke positively about the medicines training they had completed. They told us they knew how to report medicines incidents and felt confident in doing so.

A medicines policy and procedure was in place. People’s medicines support needs were documented in their care plan. Care staff recorded medicines administration on electronic Medicine Administration Records (MARs). We viewed a sample of MARs and found these were completed fully indicating that medicines prescribed had been administered appropriately. Medicines were stored safely and correctly. Some people were prescribed PRN (as required) medicines. There were clear protocols for staff on when and how to administer PRN medicines. We saw PRN medicines were administered as prescribed. However, we noted that the level of detail recorded by staff was not always sufficient. For example, 1 person had taken painkillers on 3 days and the reason recorded was ‘possible pain’. We discussed this with the manager who acknowledged this and said that further specific details would be recorded in future and that this would be discussed with staff at the next staff meeting. The manager confirmed that people requiring PRN medicines were supported by staff to take them with them during outings so they were readily available. The manager explained that they implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) and ensured that people's medicines were reviewed in line with these principles. The principles of STOMP were discussed with staff during staff meetings to help ensure staff knew what their responsibilities were in respect of this.