What the CQC found at Spring Tree Rest Home

People told inspectors they felt safe, and staff understood how to recognise and report possible abuse.

“People told us they felt safe. One person said, "I do feel safe here.” from the report

The home was clean and staff were seen using protective equipment to help control infection.

“The home was clean and free from any malodours.” from the report

People received enough food and drink, with tailored diets prepared where needed. Healthcare professionals were consulted when necessary.

“Where people had specific dietary needs, advice was sought from relevant healthcare professionals such as Speech and Language Therapists.” from the report

The provider acted during the inspection to complete fire safety checks. Inspectors also saw better mealtime support, activities and caring interactions on the second day.

“Fire safety checks were carried out and suitable checks of the environment and equipment were in place by the end of the inspection.” from the report

Fire alarm testing was not regular and some staff did not know what to do in a fire. Risk assessments were missing for some identified risks, and the home did not analyse accidents and incidents to prevent them happening again.

“Fire alarm testing did not take place on a regular basis and there were no supporting records to evidence this practice.” from the report

Medicines were not always recorded, stored or administered safely. Inspectors could not be sure that people had received medicines as prescribed, and some staff made errors despite recent training.

“We could not be assured that people had received their medication as prescribed.” from the report

Some new staff had not received key induction training, and staff did not consistently receive supervision. This was a breach of Regulation 18.

“Some staff confirmed they had not received any induction or any form of training.” from the report

Care plans did not consistently record people's wishes, preferences or required support. Mental capacity assessments were also not consistently available, affecting evidence that decisions were made lawfully and in people's best interests.

“Care records did not contain enough personalised information to enable staff to provide consistent individualised care.” from the report

There was no registered manager and the provider's audits did not identify or correct important problems. This was a breach of Regulation 17, and CQC issued a warning notice.

“The provider failed to deploy an effective governance framework to monitor and evaluate the quality and safety of the service.” from the report

Inspectors saw occasions when dignity was not fully respected. On the first day, people had little activity and social interaction, although improvements were seen on the second day.

“On the first day of inspection, we observed minimal activity and a lack of social stimulus for people.” from the report