CQC report explained · a residential care home
What the CQC found at Spring Lake
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found kind care, but unsafe hot water, unlawful restrictions and weak oversight.
Inspectors visited the home on 28 June and 1 July 2022. They observed care, spoke with staff and healthcare professionals, contacted safeguarding staff, and reviewed care records, medicines, recruitment checks, audits and other records.
People received kind and compassionate care. Staff understood people's communication needs, had completed relevant training and there were enough staff. Medicines were stored and recorded safely, and people's health and dietary needs were supported.
However, some shower outlets delivered dangerously hot water, including one linked to an earlier scalding incident. The home did not always use the least restrictive approach, communication tools were not tailored well enough, and investigations and quality checks did not identify or address root causes effectively.
The overall rating changed from Good in 2018 to Requires Improvement. Caring remained Good, while Safe, Effective, Responsive and Well-led were rated Requires Improvement. The provider must send an action plan, and CQC said it would monitor progress and return for another inspection.
Kind and respectful care
Inspectors saw staff provide compassionate care and use respectful language. People's privacy, dignity, cultural needs and religious preferences were supported.
“People received kind and compassionate care from staff who used positive and respectful language which people understood and responded well to.” from the report
Enough trained staff
There were enough staff, and recruitment checks had been completed. Staff had relevant training, induction and regular supervision.
“People were supported by staff who had received relevant training.” from the report
Health and nutrition support
People's nutritional and health needs were included in their plans. Staff worked with different health professionals, and people had annual health checks.
“People's health needs were met. People had health actions plans that enabled health and social care services to support them in the way they needed.” from the report
Medicines usually managed safely
Medicines were stored, administered and recorded safely. The provider acted immediately when inspectors identified a problem with PRN medicines being taken on outdoor activities.
“People received their medicines safely. They were supported by staff who followed systems and processes to administer, record and store medicines safely.” from the report
Unsafe hot water
seriousThree shower outlets delivered water hotter than the home's 43°C limit. One reached 56°C and was linked to an earlier scalding incident. Risk assessments, maintenance and incident follow-up were not effective.
“This included an outlet of a recent incident of scalding, which discharged water at 56ºC.” from the report
Unlawful restrictions
seriousA key lock prevented people from accessing the garden freely, and some shower rooms had keypads. The home could not show that less restrictive options had been considered.
“In both examples, the provider could not demonstrate they had considered less restrictive options.” from the report
Weak learning from incidents
seriousInvestigations did not properly consider underlying or organisational causes. Quality checks also did not always show what action had been taken when problems were found.
“We judged there were limited opportunities for organisational learning because the investigation focussed on individual errors, with less attention on root causes.” from the report
Communication tools not tailored
needs fixingThe home's visual schedules were not appropriate for most people and had not been assessed for individual understanding. This could make it harder for people to predict and control their day.
“The provider had not carried out assessments to determine people's understanding of this system and therefore visual symbols to be used.” from the report
Limited use of outdoor space
needs fixingPeople could not freely use the garden, and planned group trips did not always reflect individual choices or preferences.
“People could not freely access to unwind or take part in outdoor activities or enjoy a sunny day, as it was during the inspection.” from the report
- 01What has been done to ensure every shower outlet stays below the home's safe temperature limit, and how is this checked and maintained now?
- 02How have the restrictions on the garden and shower rooms been reviewed, and what less restrictive alternatives are in place?
- 03What changes have been made to incident investigations so that root causes and organisational issues are identified?
- 04How are communication schedules and visual aids assessed for each person, including people with visual impairment?
- 05How will people be supported to use the garden and take part in activities that reflect their individual choices?
This was an announced inspection prompted by concerns about hot water risk, with infection prevention and control also checked; inspectors assessed all five key questions. This explanation was written from the published report of 17 August 2022 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.
What inspectors found, April 2021
Inspected but not rated; inspectors were assured about infection control, with some resources suggested for further development.
This was an announced, targeted inspection on 15 March 2021. It focused on infection prevention and control during the COVID-19 pandemic, rather than a full assessment of the home.
Inspectors were assured that the home was managing visitors, shielding, social distancing, personal protective equipment, testing, hygiene and infection outbreaks. Staff understood infection control measures and had received relevant training.
The home supported contact with relatives by telephone and the internet. People were also supported with hobbies, activities, household tasks and access to the community.
The service was inspected but not rated. CQC signposted the provider to resources to develop its approach, but the report does not say that any regulation was breached.
Infection control
Inspectors were assured that visitors were screened and that the home used measures to reduce the spread of infection.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Personal protective equipment
The home had suitable PPE and staff understood how to use it safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Family contact
People were supported to keep in regular contact with relatives by telephone and the internet.
“The home had a caring approach regarding ensuring that people had contact with their relatives.” from the report
Activities and community access
Staff knew people's interests and supported activities such as music, arts and crafts, puzzles and exercise. The home also provided vehicles for community access.
“People were encouraged to continue participating in activities they liked.” from the report
Further development suggested
minorCQC signposted the provider to resources to develop its approach. The report does not explain which part of the approach needed development.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01What resources did CQC signpost you to, and what changes have you made since the inspection?
- 02How do you currently screen visitors and manage visiting arrangements?
- 03How do you make sure staff have enough PPE and continue to follow infection control training?
- 04How will my relative keep regular contact with family and take part in activities they enjoy?
- 05How often can people use the home's vehicles to access the community?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it was not a full assessment of the home and the service was inspected but not rated. This explanation was written from the published report of 9 April 2021 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.
Every inspection of Spring Lake
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- August 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- August 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- November 2017Requires improvementstayed Requires improvementWell-led: Requires improvement
- April 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 30 August 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Brent
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 74 can care for a couple. 11 years' experience on average.
“The quality of life that she's given my parents has been priceless. The peace of mind she's given my sisters and I, through a very difficult time, has been invaluable.”
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