Spring Mount

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 requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the ways people’s medicines were managed safely and good governance.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff recorded incidents and falls, and there were some examples of appropriate immediate action taken to support people’s safety. However, systems to ensure learning was identified, analysed and embedded were not effective.

Incidents and falls were not subject to consistent service-level analysis. There was no clear evidence of regular oversight to identify themes, trends or common risk factors. As a result, opportunities to take preventative action and reduce the risk of recurrence were sometimes missed.

Actions following incidents were not always clearly documented or implemented, and outcomes for individuals were not consistently recorded. Learning was not routinely used to update risk assessments, care plans or practice. This meant people were at continued risk of repeat incidents because preventative measures were not always strengthened in a timely way.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had effective systems in place to support safe admissions and transitions into the service. Pre-admission assessments were completed in line with the provider’s admissions policy. These assessments considered people’s needs, risks and preferences to ensure the service could meet them safely.

People and their relatives told us they were involved in developing care plans and had the opportunity to contribute to the information recorded. This helped ensure care reflected people’s preferences and personal histories, supporting safe pathways into the service.

The provider did not have consistent or effective processes in place to monitor safeguarding concerns, and they did not always respond to concerns quickly and appropriately.

Oversight arrangements were not sufficiently robust. There was no clear system to review the number and nature of safeguarding notifications submitted each month. This limited the provider’s ability to identify patterns or emerging themes, and to take proactive action where needed.

We also found that whilst unexplained bruising had been recorded on incident forms and body maps, there was not always clear evidence of further investigation or documented follow-up. This meant it was not evident how concerns had been explored, whether potential safeguarding issues had been escalated appropriately, or what action had been taken to reduce the risk of recurrence.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that Deprivation of Liberty Safeguards (DoLS) were appropriately applied, clearly documented and monitored, and statutory notifications to the Care Quality Commission were submitted as required.

People told us they felt safe living at the service, and relatives expressed confidence in staff.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Incident forms were routinely completed; however, the quality and detail of these records were inconsistent. Entries often lacked sufficient information to support meaningful review, including repeated statements that relatives had not been informed without a recorded rationale. This reduced assurance that people and those important to them were appropriately involved in managing risk.

Risk assessments were reviewed monthly and we saw some examples of good practice, including clear monitoring of wound care for 1 person. However, this was not consistent, and documentation was not in place for another person who also had a pressure wound.

Behavioural incidents were not always described in enough detail to identify triggers, impact or management strategies, limiting opportunities to analyse patterns and implement preventative action.

Documentation to manage known risks was not always robust. Two people had previously absconded; 1 of these people was living with dementia and assessed as lacking capacity. They did not have a Herbert Protocol in place. This is a national safeguarding scheme used by health and social care services to help locate a person quickly if they go missing. An attempted absconsion witnessed by inspectors during the assessment site visit had not been recorded as an incident. This meant learning and risk mitigation following these events were not always clearly evidenced.

Falls management was inconsistent. Where people had sustained injuries following falls, body maps had not always been completed, and risk assessments or care plans had not consistently been updated to reflect changes in risk. In 1 case, there was no falls risk assessment in place despite the person having experienced repeated falls.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Environmental safety checks and oversight were not consistently effective. All bedroom doors were locked at the time of inspection, which raised concerns in relation to people’s choice and potential fire safety. Keys were made available to some people by day 2 of the site visits, and a master key has been obtained for use in an emergency.

Fire safety arrangements required improvement. On the first day of assessment, a dining room fire door had been propped open. This was addressed the same day and remained closed thereafter. Two fire doors did not fully close when tested and immediate action was taken once this was identified. We also observed damage to newly fitted fire doors, including unsealed gaps and damaged architrave, which required completion to maintain fire integrity. The provider confirmed this work was included within their service improvement plan.

Personal Emergency Evacuation Plans (PEEPs) and associated service user lists were not consistently accurate. Some records contained incorrect room numbers or missing information, which could cause confusion in the event of an emergency and delay safe evacuation.

While we saw that concerns raised during the inspection were acted upon promptly, these issues had not been identified through the provider’s own monitoring systems. This indicated environmental oversight and routine safety checks were not sufficiently robust to identify and address risks proactively.

However, people and relatives were happy with the environment and how bedrooms had been personalised. One relative told us, “[Person] can’t do much now, but they always look peaceful. I know they feel safe here and the service have all the safety equipment for them.”

The environment was generally pleasant and welcoming. Communal areas were comfortable and well maintained, and people’s bedrooms were personalised with their own belongings. We observed dementia-friendly features, including colour-coded signage to support people to orientate themselves and maintain independence.

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.

Staffing levels were sufficient to meet people’s assessed needs. During the inspection, we observed a good staff presence in communal areas, and staff responded promptly to people requiring support. There were no delays in care observed, and people’s needs were met in a timely way.

People and their relatives’ reported staff were well trained, responsive, and understood the individual needs of their loved ones. They felt the consistent staffing team contributed to continuity of care and that there were sufficient staff numbers to meet needs safely. One relative told us, “There is always plenty of staff, [person] is so much safer at Spring Mount. One person told us, “I know there is a lot of us and it's not just me, but they help me all the time, I know them well and there is enough of them. I am safe at nighttime too.”

Recruitment processes were in place, and most recruitment records reviewed contained the required pre-employment checks. A small number of minor documents were not immediately available within the files sampled; however, this did not indicate any concerns regarding the safety of recruitment practices. Some records would benefit from improved organisation.

Staff received supervision, and sessions were completed routinely. Although the content of supervision records were brief, there was evidence staff were supported in their roles. Training records showed good compliance across mandatory and role-specific subjects. Staff told us they felt appropriately trained to meet the needs of people using the service.

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.

Most areas of the home were clean and generally well maintained. We observed handwashing facilities were generally well stocked and replenished promptly when needed.

Staff were observed using personal protective equipment appropriately and adhering to “bare below the elbow” guidance. Cleaning schedules were in place and largely completed, demonstrating regular cleaning was consistently taking place.

We also observed the use of a sanitising machine in some bedrooms, which was being used to eliminate odours and reduce the risk of infection.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines management was unsafe. MAR charts were frequently incomplete or inaccurate, with one incorrect administration not recorded or treated as an error. Allergy information was missing for all people using the service. Records did not show that medicines that had specific administration requirements were given as prescribed.

PRN protocols lacked person‑centred guidance, and for 1-person, frequent PRN use was recorded with no evidence of alternative strategies being tried. Guidance for topical medicines was inconsistent or missing and required risk assessments for flammable emollients were not in place. Patch administration was not safely managed, with no rotation charts and failure to follow controlled drug procedures.

Competency assessments were overdue, and no night‑time medicines administration meant people were at risk of delayed treatment. Medicines incidents had not been recorded since 2021, and two errors identified during inspection had not been reported, providing no assurance that errors or near misses were recognised, recorded or learned from.

However, medicines were stored securely, and availability and temperature monitoring were generally in place. Most medicines were in date; however, opening dates for liquid medicines were not always recorded. Controlled Drugs (CDs) were stored in the CD cabinet alongside other items, resulting in frequent access and reducing security. Stock counts for CDs were inaccurate due to documentation omissions.

We found no evidence of harm to people as a result of these shortfalls, and the provider took immediate action to start addressing all concerns raised during the assessment.