CQC report explained · a residential care home
What the CQC found at Springbank Rest Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely. Risk assessments were missing or out of date for some people, and inspectors found fire safety and environmental concerns, although there were enough staff and safeguarding systems were in place.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- The home did not have effective audits and quality checks. This meant concerns about medicines, risks, fire safety and the environment had not been identified by management.
What inspectors found, March 2024
Rated Requires Improvement; inspectors found caring support but unsafe medicines, poor risk checks and weak oversight.
This was an unannounced focused inspection. Inspectors visited on 25 January and 13 February 2024. They spoke with 13 people, 5 relatives and staff, observed care and a meal, checked the building and equipment, and reviewed care, medicines, recruitment and management records.
People and relatives were very positive about the care. Inspectors saw kind interactions, enough staff and a relaxed atmosphere. People were safeguarded from abuse, staff recruitment checks were completed, and the home was working within the Mental Capacity Act.
There were important safety problems. Medicines were not always managed safely, risks such as falls and choking were not always assessed or reviewed, and there were fire safety and building issues. The home also lacked effective audits and checks, so problems had not been found by its own management.
The overall rating is Requires Improvement. Safe and Well-led were both rated Requires Improvement. The inspection was focused on those two areas, while the other ratings were carried forward from the previous inspection. The previous overall rating was Good, published in April 2018.
Enough consistent staff
There was a stable staff team, with enough staff on duty to support people. Staff knew people well.
“There was a stable staff team and there were enough staff on duty to respond to people's needs.” from the report
Safeguarding systems
The home had systems for reporting safeguarding concerns, accidents and complaints. Staff had safeguarding training and understood what to do if someone might be harmed.
“Systems were in place to ensure people were safeguarded from the risk of abuse.” from the report
Positive atmosphere
Inspectors saw a relaxed atmosphere and kind interactions. Staff described the manager as approachable and supportive.
“The atmosphere in the service was relaxed and we observed kind and caring interactions between staff and people, which was indicative of a positive culture.” from the report
Medicines were not always safe
seriousThere was no system to check medicines brought in by new residents against their prescriptions. Guidance was missing in some areas, and creams were not stored correctly.
“The provider had failed to ensure safe systems for the management and administration of medicines.” from the report
Risks were not fully assessed
seriousSome people lacked falls or choking assessments, and assessments were not always reviewed after incidents. Inspectors also found risks linked to fire exits, a heater and window restrictors.
“The provider had failed to effectively assess the risks to the health and safety of people receiving care and failed to do all that was reasonably practicable to mitigate those risks.” from the report
Weak management checks
seriousAudits and regular checks were not being carried out effectively. As a result, management had not identified the problems found during the inspection.
“Systems and processes had not been established to effectively assess, monitor and improve the quality and safety of the service.” from the report
Building needed repairs
needs fixingSome toilets and bathrooms had exposed, cracked or rusty surfaces. Skirting boards and walls needed redecoration, and parts of the conservatory needed cleaning.
“There was an exposed porous surface, cracked tiles and rusty pipework in toilets/bathrooms.” from the report
- 01What has been changed so medicines brought in by new residents are checked against their prescriptions?
- 02How are staff now given guidance for creams, fluid thickeners and other medicines?
- 03Which residents now have falls and choking risk assessments, and how often are these reviewed after an incident?
- 04Have the fire exit, outdoor fire door route, bedroom heater and window restrictors been checked and made safe?
- 05What audits are now being completed, and how will you show that problems are being identified and fixed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection published in 2018. This explanation was written from the published report of 6 March 2024 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, February 2021
Springbank Rest Home was inspected but not rated; inspectors found strong COVID-19 measures but issues with water pressure, clutter and the infection-control policy.
This was an announced, targeted inspection on 14 December 2020. It looked at infection prevention and control during the coronavirus outbreak. There were 16 people living at the home.
Inspectors were assured about visitors, social distancing, admissions, PPE, testing and managing outbreaks. Staff had completed PPE training, and residents isolated after testing positive or returning from hospital.
Inspectors were only somewhat assured about the layout and hygiene of the home. Water pressure was inconsistent, some ornaments and other items made thorough cleaning harder, and the infection-control policy gave incorrect advice about separating laundry for residents who had tested positive or negative for COVID-19.
The service was inspected but not rated. This report does not give an overall quality rating or a rated score for the five questions.
PPE and testing
Staff followed government guidance on PPE and took part fully in COVID-19 testing. PPE was available where staff needed it.
“Staff were seen to be following the current government guidelines in relation to the personal protective equipment (PPE) and were engaged fully in the testing for COVID-19.” from the report
Isolation arrangements
Residents completed isolation periods in their bedrooms after testing positive for COVID-19 or returning from hospital.
“Residents completed isolation periods in their bedrooms after testing positive for Covid-19 and when returning to the home from hospital.” from the report
Staff training and support
Staff had worked with the local infection-prevention team and completed PPE training.
“Staff had engaged with the Local Authority IPC team and completed their PPE training.” from the report
Visitor and distancing controls
The home used signs about social distancing and handwashing, and inspectors were assured that visitors were protected from infection risks.
“There was signage around the home to indicate the need to social distance and to wash hands regularly” from the report
Water pressure
needs fixingWater pressure was not consistent throughout the home. The home said the fault was being rectified after the inspection.
“There were issues with the hot water in the home at the time of inspection where the water pressure was not consistent throughout the home.” from the report
Clutter and cleaning
needs fixingSome ornaments and homely items could make thorough cleaning more difficult. The home was advised to reduce clutter.
“The environment was homely but this was not always in line with current infection control guidance, the home was advised to reduce clutter where possible to aid thorough cleaning.” from the report
Incorrect laundry guidance
seriousThe infection-control policy incorrectly said laundry did not need to be separated for residents who had tested positive or negative for COVID-19.
“The IPC policy was incorrect in stating that the laundry did not need to be separated for COVID negative and COVID positive residents.” from the report
- 01Has the inconsistent hot-water pressure been fixed, and how do you check that it remains consistent throughout the home?
- 02Has the infection-prevention and control policy been corrected to give the right advice about separating laundry for COVID-positive and COVID-negative residents?
- 03What changes have been made to reduce clutter and allow thorough cleaning of ornaments and other homely items?
- 04How are PPE supplies, staff testing and resident isolation arrangements managed now?
- 05How do you keep your infection-prevention guidance up to date with current advice?
This was a targeted inspection of infection prevention and control during the coronavirus outbreak; it was inspected but not rated and did not assess the other four questions. This explanation was written from the published report of 27 February 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 Springbank Rest Home
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- March 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- April 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 4 November 2010.
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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