CQC report explained · a nursing home
What the CQC found at Spring Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found people were not always protected from harm when specialist equipment was used, and one person's health was not adequately monitored. Staffing, safeguarding, medicines and infection control systems were otherwise in place.
- Effective?
- Good
- This question was not inspected during this focused visit. The previous comprehensive inspection rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. The previous comprehensive inspection rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. The previous comprehensive inspection rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Management changes had continued and there was no registered manager. Audits and monitoring helped identify shortfalls, but relatives said communication needed to improve.
What inspectors found, December 2022
Requires Improvement; inspectors found risks with moving equipment and health monitoring, alongside ongoing management changes.
This was an unannounced focused inspection on 18 October 2022. Two inspectors spoke with people, a visitor, relatives, staff and health professionals. They observed care, checked records and equipment, and looked at the building.
The home had enough staff to meet people's needs, and medicines, safeguarding and infection control systems were in place. Permanent staffing had improved and agency use had reduced. People and relatives described kind care, and staff morale was positive.
However, inspectors found that people were not always safe when equipment was used to move or transport them. A wheelchair was used without a lap belt, and a hoist sling could not be reliably identified. Staff also failed to monitor one person's health when they were unwell. The home was also without a registered manager, and management changes had continued.
The overall rating remained Requires Improvement, as did Safe and Well-led. The inspection only reviewed Safe and Well-led. The other ratings were carried forward from earlier inspections.
Staffing had improved
Permanent staff had been recruited and the use of live-in agency staff had fallen. Inspectors found enough staff on duty to meet people's needs.
“People told us when they needed assistance staff were available to support them.” from the report
Kind permanent staff
People and relatives spoke positively about the kindness of permanent staff. Relatives said staff knew their family members well.
“All of the relatives spoken with said they felt their family members were happy living in the service, this was confirmed by the people who used the service we spoke with.” from the report
Safeguarding systems
Staff had safeguarding training and understood how to report concerns. Reported concerns were passed to the appropriate professionals.
“There were systems in place to reduce the risks of abuse.” from the report
Learning from incidents
Complaints, falls and other incidents were analysed, with steps taken to reduce the chance of problems happening again.
“Complaints, concerns, incidents and accidents were addressed and analysed, and systems put in place to reduce them reoccurring.” from the report
Unsafe moving equipment
seriousA person was transported in a wheelchair without a lap belt. A hoist sling had no clear size or owner and its inspection label was out of date.
“Therefore, we were not assured that systems in place to safely transfer people using specialist equipment were safe.” from the report
Health was not monitored properly
seriousStaff knew one person was unwell but did not check their vital signs. A district nurse later found the person sufficiently unwell to require an ambulance.
“Staff were aware the person was not well, but had failed to monitor the person's condition and check their vital signs” from the report
No registered manager
needs fixingThe home had experienced continuing management changes and did not have a registered manager. Relatives also reported that communication needed to improve.
“The lack of consistent management had gone on for some time.” from the report
Recruitment records
needs fixingOne staff member did not have independent references. The only testimonial had been supplied by a family member.
“However, one staff member did not have independent references taken up. They had one testimonial that had been supplied by a family member.” from the report
- 01How are you now making sure every wheelchair used for transport has the correct safety belt?
- 02How are slings labelled so staff can confirm the correct size, owner and inspection status before use?
- 03What process do staff follow when someone appears unwell, including when vital signs must be checked?
- 04Has a registered manager now been appointed, and how will management stability be maintained?
- 05What action was sent to CQC after the Regulation 12 breach, and what has been completed?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 16 December 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, September 2021
Requires Improvement; inspectors found some safety systems working, but care and risk records were not yet consistently reliable.
The home provides personal and nursing care for 35 people, including some people living with dementia. The inspection was unannounced and took place on 4 August 2021, with records reviewed remotely afterwards.
Inspectors found that risk assessments and care plans did not always give staff clear, up-to-date guidance. This included risks linked to choking and repositioning. The home was reviewing the records, but the work was not finished or fully in use.
There were systems for medicines, safeguarding, staffing, recruitment, equipment checks and infection control. A new manager had started making improvements, but the home was still rated Requires Improvement for Safe and Well-led.
This was a focused inspection of Safe and Well-led only. The overall rating fell from Good at the previous inspection because of the findings in these areas. The other three ratings were carried forward from the previous comprehensive inspection.
Equipment and environment checks
The home regularly checked equipment and the environment, including mobility equipment and fire safety, to reduce risks.
“The environment and equipment used was regularly checked to reduce the risks to people.” from the report
Safeguarding and recruitment
Staff had safeguarding training and knew how to report concerns. Recruitment checks were used to reduce the risk of unsuitable staff being employed.
“Staff were recruited safely, this included checks to reduce the risks of staff being employed who were not suitable to work in this type of service.” from the report
Positive staff relationships
People, relatives and staff gave positive feedback about the new manager and the kindness of staff. Relatives said their family members were happy living at the home.
“All of the relatives spoken with said they felt their family members were happy living in the service” from the report
Monitoring and improvement
Audits, complaints, incidents and feedback were used to identify problems and plan improvements.
“A programme of auditing and monitoring supported the provider and management team to identify shortfalls and act to reduce identified risks.” from the report
Incomplete risk guidance
seriousSome risk assessments were out of date or inconsistent. They did not always explain how staff should reduce risks in daily care, including choking and repositioning.
“People's risk assessments did not always provide enough guidance to staff in how to reduce the risks to people in their daily living.” from the report
Care records not yet complete
needs fixingCare plans did not always explain people's conditions, anxiety, distress or independence clearly enough. The review of records was still in progress.
“Shortfalls in recording had been picked up in the provider's own monitoring systems and the manager was in the process of reviewing and updating care records” from the report
Negative wording in records
minorSome records described people's wellbeing in negative terms rather than giving a balanced account of their needs and support.
“Some recording was written in a negative way when describing people's wellbeing.” from the report
- 01Have all care plans and risk assessments now been updated, especially for choking, pressure ulcers and repositioning?
- 02How do you check that staff are following the latest guidance in each person's care plan?
- 03How many permanent staff vacancies remain, and how often are agency staff being used?
- 04What changes has the new manager made since starting on 5 July 2021?
- 05How do you make sure records describe people's wellbeing and behaviour in a respectful, positive way?
This was an unannounced focused inspection of Safe and Well-led only; the other three key-question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 11 September 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 Lodge
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2017Goodstayed GoodSafe: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 January 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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