CQC report explained · a residential care home
What the CQC found at Spring Mount
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2020
Inspected but not rated; the home had fixed previous breaches, but its overall Requires Improvement rating was not changed.
This was a targeted inspection on 15 and 17 September 2020. Inspectors checked whether the home had acted on previous requirement notices about safe care and treatment and quality monitoring. They also checked infection control arrangements during the COVID-19 pandemic.
Inspectors found that the previous shortfalls had been addressed. Risks and medicines were managed safely. Records about people's capacity and best-interest decisions were clearer, but still needed to show people's and representatives' involvement more fully. Quality checks, care plan reviews and staff training had improved.
The home was clean and well maintained. People and relatives were positive about the care, and staff understood people's needs. This was not a full inspection, so the ratings were not reviewed and the overall Requires Improvement rating from the previous inspection remained unchanged.
Safer risk management
Risks to people's health and safety were assessed. Staff understood people's needs and supported them safely with moving and handling.
“Staff understood people's needs well and how to manage the risks they were exposed to.” from the report
Medicines managed safely
Medicines systems had improved. Staff received regular training and their competence was checked every six months.
“Staff who supported people with medicines received regular training. Competency assessments were completed every six months.” from the report
Good infection control
The home was clean and well maintained, with measures to prevent infection and regular testing available for staff and people.
“The home was clean and well maintained. Effective measures were in place to prevent and control the spread of infection.” from the report
Improved management checks
The home had improved its audits and acted when issues were found. Previous shortfalls, including fire drills, care plan reviews and staff training, had been addressed.
“Quality assurance systems had improved. Audits were in place and we saw action was taken when issues were identified.” from the report
Supportive care
People and relatives were positive about the care. Inspectors saw people supported gently, and meals were provided sensitively and without rushing.
“The mealtime experience was relaxed and sociable. Where people needed help with their meals this was done sensitively and not rushed.” from the report
Best-interest records
needs fixingRecords did not always clearly show how people and their representatives had been involved in individual decisions. Inspectors recommended that the provider seek further advice about the Mental Capacity Act.
“Individual decisions need to be recorded in a clearer way to show the involvement of people and their representatives.” from the report
As-needed medicines details
minorProtocols existed for medicines given when needed, but inspectors said they needed more person-centred details so staff could give them consistently.
“However, they would benefit from more person-centred details to ensure medicines were administered consistently.” from the report
- 01How will you make sure best-interest records clearly show the involvement of the person and their representative?
- 02What person-centred details are now included in protocols for medicines given when needed?
- 03How often are care plans reviewed, and how do you check that they remain current and person-centred?
- 04How do you monitor whether the improvements from the previous inspection are being maintained?
- 05What was the outcome of the next comprehensive inspection after this targeted visit?
This was a targeted inspection of specific concerns under Safe, Effective and Well-led, plus infection control; it did not assess the full five key questions, so the previous ratings carried over. This explanation was written from the published report of 9 October 2020 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, July 2019
Rated Requires Improvement; inspectors found unsafe medicines and care practices, incomplete records, and inconsistent dignity and support.
Inspectors visited the home without warning on 4 December 2018 and 7 January 2019. They spoke with people, visitors, managers and staff, observed care and a meal, and checked care, medicine, staff and management records.
People said they felt safe and liked the food. There were enough staff, the home was clean, and staff were trained and supported. Inspectors also saw many warm interactions and people could move around the home and gardens freely.
However, people were not always moved safely and medicines were not always stored, supplied or recorded safely. Care plans and records were often incomplete or out of date. Inspectors also found problems with dignity, health support, activities and the systems used to check quality and safety.
All five areas were rated Requires Improvement. The overall rating had fallen from Good at the previous inspection in September 2016. The management team acted quickly on some problems found during these visits, but the provider was in breach of two regulations.
Enough staff
Inspectors found enough staff to care for people safely and keep the home clean. Recruitment checks were also in place.
“There were enough staff on duty to care for people safely and keep the home clean.” from the report
Clean home
The home was clean, tidy and free from unpleasant smells. Staff used protective equipment appropriately.
“The home was clean, tidy and odour free.” from the report
Positive relationships
Inspectors saw many positive interactions. People appeared comfortable with staff and could follow flexible daily routines.
“We observed a lot of positive interactions between staff and people who used the service.” from the report
Access to outside space
The grounds were secure and people could use the gardens freely. Several doors gave people access to the outside.
“The grounds were secure to keep people safe.” from the report
Staff training
Most staff training was up to date and covered areas including safeguarding, moving and handling, dementia and person-centred care. Staff said they felt supported.
“Staff told us training opportunities were good and there was plenty of training on offer.” from the report
Unsafe moving and handling
seriousStaff did not always follow the person's moving and handling plan. Inspectors also saw a person pulled from a chair by their hands when two staff were required.
“We were concerned the use of the moving and handling belt might not have been appropriate.” from the report
Medicines were not consistently safe
seriousSome medicines and prescribed milkshakes were unavailable, records did not always match stock, and medicine training was out of date for one staff member. Controlled medicine keys were also left in the medicines cupboard.
“Medicines were not always stored, managed and administered safely.” from the report
Incomplete care records
needs fixingCare plans were not always accurate or up to date. Records did not consistently show people's capacity, best interest decisions, consultations with relatives or end of life wishes.
“People's care plans were not always up to date and person centred.” from the report
Privacy and dignity
needs fixingInspectors saw a person's face and hands wiped without the person being spoken to, and the person was not helped to change wet clothing. Some people also had dirty fingernails, greasy hair or damaged footwear.
“People who used the service were not always treated with dignity and respect.” from the report
Health and nutrition records
needs fixingFluid and food records did not give a clear picture of what one person had received. The person was not given a drink during part of the night and there was no care plan explaining this.
“The records of the same person's food intake were not detailed enough to give a clear picture of what they had eaten.” from the report
Quality checks missed problems
seriousThe provider's monitoring systems did not identify several safety and care problems, including hot radiators and the lack of night staff fire drills.
“Systems and processes for monitoring the quality and safety of the services provided were not always operated effectively.” from the report
- 01What changes have you made to ensure staff always follow each person's moving and handling plan?
- 02How do you now check that medicines are available, stored securely, administered correctly and recorded immediately?
- 03How are care plans kept up to date, including people's capacity, best interest decisions, health needs and end of life wishes?
- 04What has changed to protect people's privacy and dignity during personal care and meals?
- 05How do you check that the provider's quality monitoring system finds problems promptly, including fire safety and hot surfaces?
This was an unannounced comprehensive inspection covering all five questions and the overall rating; inspectors spoke with two people and two visitors and reviewed three care records and selected medicine records. This explanation was written from the published report of 16 July 2019 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 Mount
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- October 2020Inspected but not ratedcurrent ratingSafe: Inspected but not ratedEffective: Inspected but not ratedWell-led: Inspected but not rated
- July 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2017GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 5 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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