Springbank House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst the provider had a proactive and positive culture of safety based on openness and honesty, not all incidents were reported on. Senior staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

People said, “Staff are ok but lots have left, I don’t think they really understand me or listen to me,” and “Good staff I think, but I am not an expert, don’t always tell us what’s happening.

Safety concerns and events were not always reported on, there was no reflection of how incidents occurred, steps taken to prevent it happening again or information on how lessons were learned to embed good practices going forward. Staff could tell us examples of how they managed incidents, but outcomes and strategies were not always clearly documented or recorded in risk assessments. This meant it was not always possible to monitor escalations of risk, improvements and positive outcomes for people. The management team were responsive to this feedback and immediately produced new documents to record incidents, actions taken and lessons learnt to mitigate risk.

Safety checks were undertaken by staff, this included environmental checks, and risk assessments for both physical and mental health. However, during our site visit we noted ligature risks that had not been risk assessed despite a person saying they may harm themselves. This was addressed immediately by the interim manager.

Staff worked alongside other adult social care and health organisations to ensure people received appropriate care. There was regular contact with local authority, social worker, mental health team and doctors. Staff told us they knew the health teams well and told us of collaborative teamwork. "We do work well with the social care teams and community teams, they are always helpful and answer our queries, but we are pushed back sometimes (example given) but we don’t give up."

The provider worked well with people and healthcare partners to establish and maintain safe systems of care, pre-admission risk assessments were put in place with the information plan from the placement team. We were told by staff that they would always undertake an assessment of the person before they arrived at the home to ensure they could meet peoples’ needs. Staff made sure there was continuity of care, including when people moved between different services.

People were supported to maintain their health, attend appointments both inside and outside of the service. This was confirmed by people. People's care records showed referrals had been made to healthcare professionals where concerns had been identified. The management team worked to ensure continuity of care, including when people moved out of the service and on to new placements. When people were supported to go to hospital a version of the care plan and risk assessment went with them. These ensured that hospital staff have vital information about the person and their health.

The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. T

Discussions with people and staff members, told us that not all incidents and events had been reported to the safeguarding team. Examples of these were discussed with the provider, and a policy immediately introduced, to ensure all incidents regarding people were reported on to ensure a multi-disciplinary approach as well as transparency for the health professionals involved in the person’s care. during the assessment process, we were given evidence that some incidents did not reach the criteria of safeguarding.

Staff had received safeguarding training and were clear on how to report any concerns they had. Staff told us, “I would report any concerns to the manager and expect them to deal with it appropriately, I know how to contact the local authority and safeguarding team.” Another staff member said, “Instructions and telephone numbers are in the office, we also get regular training.”

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS) The service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. There were no specific DoLS in place at this time. Best interest meetings were held with the individual person when items were removed to ensure their safety.

The provider did not always work well with people to understand and manage risks.

Effective systems were not always in place to assess, monitor and mitigate risks to people and keep them safe. We identified some people’s needs were at risk of not being met in respect of management of specific risk. This was because not all relevant information to keep people safe was consistently reflected in care plans and risk assessments. For example, in one persons’ risk assessment it stated staff administered all medicines due to potential of taking too many to harm themselves intentionally, in the care plan it stated they self-administered all medicines. This was fully discussed with the management team. Action was immediately taken.

Not all care plans included up to date guidance for staff about triggers and de-escalation techniques for staff to use to help re-assure the person. Daily records were not always consistent in documenting support given to people’s escalating mental health changes. For example, despite a person stating they wanted to harm themselves, and due to that conversation was placed, on a crisis management form, they were given an item that enabled them to harm themselves. This was fully discussed and a new care plan system to mitigate risk and training provided for staff will be implemented in the near future.

Systems and procedures were in place for unusual events, such as fire, loss of power, and other emergencies. Staff received training in areas of potential risk such as first aid and health and safety. Personal Emergency Evacuation Plans (PEEPS) had been completed for each person. PEEPS give staff or the emergency services detailed instructions about the level of support a person would require in an emergency such as a fire evacuation.

The provider was aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. People told us that the premises and their room was safe.

A staff member told us, “There is a maintenance book we record any issues,” and “We look after the house.”

The environment was clean and well maintained. Environmental risk assessments had been completed. The provider had conducted comprehensive checks, risk assessments and audits that were used to ensure a safe environment. There were people at risk of self-harming and there were minimal records regarding how staff assessed their room or the service for possible risk. There were some ligature risks identified in one lounge that was immediately addressed.

Staff confirmed that they had attended fire drills and undertaken fire training. Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, staff safety and welfare. There was a business continuity plan which instructed staff on what to do in the event of the service not being able to function normally, such as a loss of power or evacuating of the property.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We did not receive any concerns regarding staffing levels, from people or relatives. One person said, “Staff are here, they accompany me out and I think there are enough of them.” People and visitors had noticed the staff turnover was high. Comments from relatives included, “I am not aware of any problems. I have not been informed of any. I have just noted myself that there has been quite a turnover of staff there recently.” One person said, “I miss some of the staff.”

Staff received training and regular supervision. The training programme seen showed gaps in staff training and we were provided with a booking programme that assured us that training was being monitored and booked. We asked that the manager ensure that appropriately trained staff are deployed at all times until all training is up to date. Staff told us that they had not always had regular supervision, but this was being undertaken by the interim manager. It was important for staff to have support provided by supervision due to the different managers over the past year.

Staff had been safely recruited and staff files contained all of the required documents for example, references, employment histories and Disclosure and Barring Service (DBS) records. DBS help employers make safe recruitment decisions. Staff told us they had an induction period where they carried out initial training and were given opportunities to shadow more experienced staff.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean throughout. Staff had all received training in infection prevention and control (IPC) and there was a large supply of personal protective equipment (PPE) which was used appropriately by staff.IPC and PPE policies were in place and were reviewed each time government guidelines were updated.

The processes for safe medicine management were in place. However, the provider had not always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning and monthly review. This was because self administration rationales and safeguards were not consistently recorded in a persons’ care plan and risk assessment. Negative changes to a person’s mental health had not triggered a review of them self-medicating and managing their medicines, and had not been discussed with that person.

As required medicines (PRN) had been prescribed, there were generic protocols to support the giving of them, but these were not person specific and staff were not recording the outcome effect of the medicine. There was also one person who was on a PRN medicine every day and this needed to be reviewed by the GP to consider a regular prescription.

Staff supported people to have their prescribed medicines and followed best practice for administering medicines. Staff documented medicines in care plans and made them available when people moved between healthcare settings.

The staff worked closely with the GP and had had support from the Medicines Optimisation in Care Homes team, (which is a program by NHS England, which focuses on improving medication management for residents) to ensure medicine management was safe.

There was a dedicated clinical room and peoples’ medicines were stored in an appropriate lockable cupboards or in their bedrooms if they were self medicating. Bedroom and clinical room temperatures were checked and recorded daily to ensure medicines were stored at the correct temperature. Medicine administration records (MAR) were completed and if gaps identified were followed up to ensure people got their medicine as prescribed.

Staff who gave medicines had the relevant knowledge, training and competency that ensured medicines were handled and stored safely. We observed staff giving medicines safely and that they were recorded accurately on the MAR. Risk assessments were in place for certain medicines.