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. Risk was assessed and continually monitored. Staff understood how to keep people safe and had received suitable training. There were enough staff and systems in place to ensure they were recruited safely. The provider had effective systems to prevent and control infections and maintain the safety of equipment and the environment. Information was shared and lessons learned when things went wrong. People's medicines were not always managed safely. At our site visit 24 July 2024 we found that there was no documentation to demonstrate that reflective conversations took place following incidents of self-harm and that people's medicines were not always managed safely. We raised this with provider who acted quickly to address the concerns and improvements were implemented."

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider told us that lessons were learnt from accidents and incidents. Information was shared with staff to try and prevent re-occurrence. Following incidents of self-harm, the provider told us that staff were debriefed and people involved were invited to be part of these conversations. However, they were unable to demonstrate this as these conversations had not been recorded. A person told us, “We can sit and talk to staff. Sometimes it’s hard because I know I have done something I shouldn’t, but I don’t want to talk about it.” Another person told us, “I think they are honest, but I had to tell them I hadn’t got my pills for two weeks. They know now but they did say they would find out why.”

Staff feedback was mixed regarding training and support available and if lessons were learned following accidents and incidents. For example, one staff member was unsure. One staff member was unsure of what steps were being taken to prevent self-harm. They were able to discuss removing items from the persons room but were unsure about steps to take to prevent substance taking. Another staff member told us, “We look for signs of alcohol or substance abuse. We get guidance on how to spot it. We would then talk to the person to find out what had happened and if there were any triggers involved.”

Safety concerns and events were investigated and reported on, and lessons were learned to embed good practices. The provider had used learning from events/incidents that have occurred. For example, securing ligature training following recent incidents and a ligature grab bag. Safeguarding investigations were used by the management team as learning to improve outcomes for people. We were shown improved documentation regarding risk management. This had also improved on the floor risk management for specific high risk situations. Safety checks were undertaken by staff, this included environmental checks, and risk assessments for mental health. This enabled the management team to embed the culture of continuous improvement. Accidents, incidents and changes were discussed and documented in meetings and in supervision meetings. Critical incident debrief records have been introduced since our last visit, and completed following an incident. People involved in the incident were invited to a incident debrief but do not always wish to attend. The management team have just introduced a critical incident drill which allows staff to respond whilst on camera and then reflect on how it felt and self actions to go forward.

We spoke with three people regarding how they had come to live at Springbank House. Comments included, “I had been living somewhere else and my social worker discussed my options. I’m not sure now because I was not in a good place whether I made the decision but it was a good decision anyway”, “I have just been diagnosed with autism which makes sense and now discussing whether I need to move on, but I think I would like to stay here” and “I make my own decisions. Staff support me to attend my appointments. I need their support and they are there for me.”

The management team told us how they met and assessed people before they moved into the home to ensure their needs could be met safely. A staff member told us, “There have been some difficult admissions. Sometimes the information is not totally accurate and its only as they settle in, we find out things that had been omitted.”

A health and social care professional told us how staff worked with them to ensure a person received the appropriate care and support as their mental health needs changed. They told us, “Communication is improving between us and the service, which really helps joined up working.”

Assessments of people’s needs took place before they moved into the home to ensure their care needs could be met. This included ensuring that they were a ‘good fit’ with other people already living in the service. People were supported to maintain their health, attend appointments both inside and outside of the service. People's care records showed referrals had been made to health and social care professionals when concerns had been identified. Whilst we were told that people were assessed before a placement at the home was offered, the documentation to support this was not robust. It lacked detail about peoples’ reasons for coming to live in the service and what the long-term goals were, such as preparing to move on to supported living or living independently. This was acknowledged by the area manager, and improvements had been made and were on-going. The management team worked to ensure continuity of care, including when people moved out of the service and on to new placements. When people were supported to go to hospital, information sheets were used. This ensure that hospital staff have vital information about people, including their mental health and physical health needs.

Due to their specific health problems people were reluctant to share their experiences. One person was able to share their experience of being involved in a safeguarding and said they felt listened to.

Staff told us they received safeguarding training, and they knew what actions to take if they were concerned someone was at risk of harm through abuse or discrimination. A staff member told us, “Types of abuse are bullying, discrimination, neglect and emotional, we get training to know what to look for.” Another told us, “We all have had training, we go through scenarios as well, it also links into the mental health act.” Staff told us if concerns regarding people were identified they would inform the management team. They shared that they had been involved in a safeguarding and had been involved in decisions and outcomes. Staff told us they were aware how to contact the local authority safeguarding team if they felt concerns were not addressed. The area manager told us how they identified and reported any safeguarding concerns. They told us they were confident that staff would identify and report safeguarding concerns appropriately.

We saw empathetic interactions between staff and people. Staff were calm, which supported people to remain calm. We saw staff and people interacting in a positive way.

There was a safeguarding and whistleblowing policy in place, and staff confirmed they had read the policies as part of their induction and training. From reviewing organisational policies, we saw that procedures had been correctly followed, and the provider had made referrals as required to the local authority and notified CQC appropriately. The management team were aware of the guidance regarding deprivation of liberty safeguards (DoLS) and all staff received appropriate training. At this time, there was no one that required a DoLS submission. Best interest meetings were held when required and these were clearly documented. The people living at Springbank House all had capacity to make decisions even if they weren’t thought to be in their best interest.

People told us staff supported them to manage risks and stay safe. Comments included, “I have talked to the staff about risk, I know the risks and talking them through, it helps and I can tell staff how I want it managed” and “My biggest challenge is when I feel low, I can hurt myself, so staff do keep an eye on me.”

Staff were able to tell us about people and the risks associated with their care. They told us how they supported them safely. This included management of behaviours, mobility and when people may become distressed. Staff knew the people they supported well.

Communal areas were safe and had been risk assessed to ensure they are safe for the people who live there. Staff were mindful of ligature risks and of objects that may be used by people to themselves. The fire emergency documents, and personal emergency evacuation plans were kept in a locked box attached to an outside wall by the main entrance. However, staff working were not sure of where the key was and therefore in an emergency would place people and staff at risk. This was immediately addressed, and a key produced. Following the site visit a fire grab bag has been introduced. We identified that the personal emergency evacuation plans were not in place for all people who lived in the service. These were immediately undertaken and produced during the site visit.

Since the last visit, the area manager and team had reviewed and improved support plans and risk assessments. Support plans contained the individual risks to people and included clear guidance for staff on how to manage and minimise risks. Alongside the support plans, there were individual de-escalation plans for each person. The de-escalation plans were reviewed for effectiveness after each incident to ensure they work. The management team undertook an analysis of incidents and accidents and referrals were made for additional support where required, for example, in reach mental health team, and GP /consultant involvement. While systems and procedures were not always in place for unusual events such as fire, the provider responded quickly when we identified shortfalls during our site visit and necessary improvements made to address them

People told us that the premises and their room was safe. A person told us, “I clean my own room with staff support. Staff check it.”

A staff member told us, “We do audits and check rooms and communal areas daily, the laundry room as well. We are very vigilant we have to be. Past incidents have been learnt from.” Another staff member told us, “We have a maintenance book we can report any issues in. We look for any hidden dangers because we have people here who are very vulnerable.”

The environment was clean and well maintained. All equipment was checked regularly and in good working order. Kitchen cabinets were assigned to people, so they had their own provisions, and these were lockable. Fire equipment was in place and tested regularly. Staff didn’t know how to access the fire box which was located outside the building, as the key was not easily accessible. Personal evacuation emergency plans (PEEP’S) were not current, and these were updated during the first site visit.

Since the last visit environmental risk assessments had been completed. The provider had conducted comprehensive checks, risk assessments and audits that were used to ensure a safe environment. We identified that the fire emergency documents, and personal emergency evacuation plans were kept in a locked box attached to an outside wall by the main entrance. Staff were not sure of where the key was and therefore in an emergency would place people and staff at risk. This was immediately addressed, and a key produced. Following the site visit a fire grab bag has been introduced for ease of access in the event of a fire. Staff completed regular fire evacuation drills and any learning from them had been taken forward. Staff confirmed that they had attended fire drills and undertaken fire training. Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, staff safety and welfare. There was a business continuity plan which instructed staff on what to do in the event of the service not being able to function normally, such as a loss of power or evacuating of the property.

During this site visit we did not receive any concerns from people regarding the availability of staff. A person told us, “I have no grumbles. It was difficult a few months ago because there were some people who were always wanting staff now it’s better.” any concerns from people regarding the availability of staff. A person told us, “I have no grumbles. It was difficult a few months ago because there were some people who were always wanting staff now it’s better.”

Staff told us there were enough staff. A staff member told us, “Staffing is ok. We have the management team here as well who will always respond if needed.” Another staff member told us, “We have enough of us. Of course, its busy if there has been an incident or someone is unwell, but more staff can be asked for.” Staff confirmed that they had received an induction and received regular supervision.

During the site visit we saw staff were available when needed and it was well organised with people’s needs. Staff spent time with two people who were awake at the time. In the communal areas the interaction was calm and unrushed.

Following the last assessment inn April 2024 supervision processes were now in place and took place every three months. Care delivery was supported by records that evidenced that people’s care needs were being met by sufficient numbers of staff. Staff training was in pace to meet peoples specific physical and mental health needs. The training programme showed that staff had undertaken essential training that is required. However, service specific training has not been undertaken, for example, schizophrenia, diabetes, and drug and alcohol awareness. The lack of specific training to support staff to provide safe care had the potential to place people at risk from unsafe care. However, we have received confirmation that specialist training has now been completed. Recruitment processes were robust, with the provider undertaking checks on new staff prior to them starting work.

People told us the home was always clean. A person told us, “Very clean. It’s a nice place to live.” However, there had been complaints from neighbours regarding the amount of rubbish and overflowing bins which had been dealt with.

Staff told us they were responsible for the cleaning of the home, supporting people with their personal room, communal areas and the laundry.

The premises were clean and well maintained. This included the garden. There were two kitchens for people to use and both were clean and hygienic. Most people were supported with their laundry by staff. There was plenty of personal protective equipment (PPE) available.

The provider followed best practice guidelines regarding the prevention and control of infection which was updated as guidance changed. The provider’s infection prevention and control policy was up to date and all staff had received infection control and food hygiene training. Cleaning schedules were in place and were up to date and regular audits were carried out and actions planned to address any shortfalls.

We received mixed feedback about medicines. Comments included, “I haven’t had my prescribed medicines for two weeks since coming out of hospital” ,“I get my medicines. If I have a question about them staff will find out the answer” and “I would like to have my own medicines, but I am not well enough yet.”

We received mixed feedback from staff about medicines. Staff who gave medicines told us they had received medicine training and had been assessed as competent. However, not all staff felt confident in giving medicines. One member of staff, due to senior staff changes, was pre- maturely trained in medicine giving despite being in his probationary period and first three months of employment. During the assessment process we were contacted by a staff member who had concerns regarding the safe management of medicines. We were told that it was normal practice for day staff to dispense ‘as required’ (PRN) medicines for anxiety into a pot for untrained night staff to give. Following the assessment the provider told us that staff who give people their medicines were given further support and training.

Improvements were needed to the processes associated with medicine management. Medicine administration charts (MAR) were unclear with missed signatures, crossing outs. There was no corresponding document kept that recorded people refusing their medicine. In the cupboard, loose in medicine pots were unlabelled tablets that we were told had been dispensed to a person but not taken. It was not possible to track who these tablets belonged to. We have received information that on occasions that ‘as required’(PRN) medicines are potted up and left out for night staff, this included diazepam. We have brought this to the attention of the management team to investigate. Protocols for ‘as required’ (PRN) medicines were in place for most people but lacked specific detail of symptoms that the person may be experiencing. There was also no record kept of whether or not the medicine was effective. The MAR charts were printed off by staff and not the medicine provider and that meant there was more chances of errors in transferring over the instructions for medicines such as dosages and timings. This was confirmed by a recent error where a person did not receive their prescribed medicine for two weeks following discharge from hospital. Changes and stoppages to medicines were not signed and dated by two staff members and this made it difficult for staff to track and check changes with the medicine prescribers. These issues have the potential to place people at risk of receiving treatment that was not safe, inconsistent or not appropriate for their needs. Medicine audits were completed each month. These had not identified the issues we found. Despite these concerns we found aspects of good practice. Following the assessment, we were told about improvements that had been made by the provider. The medicine community optimisation team had been contacted for support and guidance. The medicine provider was now sending MAR sheets with the medicines.