What the CQC found at The Spinal Unit Action Group

People told inspectors that staff were caring. Inspectors observed patient, attentive interactions and saw that privacy and dignity were respected.

“Staff were polite, patient, attentive and caring in their approach; they took time to listen and to respond in a compassionate manner.” from the report

Inspectors found enough staff to support people safely. Staff said they were not rushed or pressured.

“All of the staff we spoke with said there were enough of them to deliver safe care and that they never felt rushed or pressured.” from the report

Staff had training relevant to spinal injuries and bowel management. The records showed training had taken place, although the central training record needed updating.

“We saw some records which showed that staff also accessed specialist training from the Spinal Unit which included spinal injury specific treatment such as neurogenic bowel function care.” from the report

People could choose where and when to eat, use adapted kitchens and take part in activities and community life. The home had adaptations to support wheelchair users.

“People living at the home had the option of eating either in their own bedrooms or in the communal dining room.” from the report

The home had introduced clearer records for medicines given when needed and for creams. This addressed part of the medicines concern found at the previous inspection.

“We saw that procedures relating to medications had improved.” from the report

Inspectors raised concerns about evacuation plans and the building layout on the first visit. By the second visit, evacuation plans had been updated and new fire safety equipment had been installed.

“On the second day of our inspection, we saw that the registered manager had updated the PEEPs for everyone at the home.” from the report

Some risks were not assessed in enough detail or had no specific assessment. This included autonomic dysreflexia, bowel care and pressure sore management, creating a risk that staff might not know what to do.

“Risks to people's health and safety were not always assessed and mitigated.” from the report

Audits did not identify some of the concerns found by inspectors. The provider did not keep clear action plans showing what needed to improve and whether it had been completed.

“The system had not identified some of the concerns we highlighted at this visit in respect of risk assessments and record keeping.” from the report

Some staff said they had informal supervision, but there were no recorded dates or documents for these meetings. The training matrix also did not show all completed training.

“There was no documented records or dates of any supervisions taking place.” from the report

Care plans varied in quality. Some were personalised, but others were vague and had not been formally reviewed as often as needed.

“There was evidence contained within care files that people had been consulted with, with regards to the delivery of their care however people's care plans were not always reviewed on a formal basis regularly.” from the report

The complaints policy did not explain clearly who to contact or provide a confidential way to raise concerns. The complaints records were loose papers rather than an organised log.

“The complaint policy did not fully support people to complain freely as there was no confidential means of raising issues or concerns.” from the report

Inspectors were concerned that the home's friendly approach could blur boundaries between staff and people living there. The provider agreed to review its policies and guidance.

“The service promoted and encouraged staff to develop personal relationships with people living at the home.” from the report