Spring Mount

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 61 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

We found some governance and quality monitoring processes did not fully support the culture of continuous improvement. These gaps limited assurance that documentation, oversight, and learning processes fully reinforced the values and culture described by staff.

However, staff meeting minutes reflected the values of the service and demonstrated these were regularly shared and discussed with staff. Staff spoken with were able to describe the direction and culture of the service, particularly the emphasis on providing a non-restrictive environment where people are supported to move freely and maintain their independence.

Overall, staff demonstrated a clear understanding of the service’s shared values and approach, but improvements were required in monitoring and governance to ensure the culture of the service was consistently supported and embedded in practice.

Leaders were committed and knowledgeable, but some aspects of oversight, role clarity, and day‑to‑day visibility needed further development to fully support consistently effective leadership across the service.

As leaders, both the registered manager (RM) and the nominated individual (NI) demonstrated strong knowledge of the service and the needs of people living there, alongside a clear drive and passion for delivering high-quality dementia care in a positive and person-centred way.

However, leadership visibility within the service was not consistent. While a team leader had been appointed with responsibility for medicines management, we identified a number of shortfalls in medicines processes, indicating a need for further training and upskilling to ensure this role is carried out safely and effectively.

Clear roles, responsibilities, and working relationships between the NI and RM were not yet fully established. Overall, while leaders were clearly committed and passionate, strengthening leadership presence, role clarity, and support structures would help embed a consistently well-led, safe, and effective culture throughout the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff had received safeguarding training and were aware of the service’s freedom to speak up policy. Staff told us they felt able to raise concerns and described an open, honest, and supportive culture where issues could be reported without fear.

This demonstrated staff felt listened to and confident that any concerns would be taken seriously, contributing to a culture of transparency, accountability within the service.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The recruitment process was fair and inclusive, with health questionnaires completed to ensure the provider was aware of any reasonable adjustments required to support staff. Staff told us they had not experienced any unfair treatment and described the registered manager as supportive.

Staff reported high morale, reflecting a positive and inclusive working environment where equality and respect were embedded in day-to-day practice.

We found the service promoted equality, fairness, and inclusivity for all staff, supporting a respectful and motivated workforce.

Governance systems were not sufficiently robust and require strengthening to ensure effective oversight and quality assurance.

Audit processes lacked evidence of detailed scrutiny, with overview documents frequently stating “all OK” without demonstrating checks of key areas such as kitchen records, care records, medicines management, home hygiene, and maintenance. Medicine audits did not accurately reflect medicines practices within the service and were overly simplistic in their format.

There was no clear evidence of analysis or trend monitoring in relation to accidents, incidents, or falls. We also did not see evidence of audits being completed on repositioning charts to ensure these were completed routinely and in line with assessed needs, nor was there evidence of review of observations for people who present with aggression. Inconsistencies were identified in service user lists and PEEPs documentation, which had not been identified or addressed through internal review processes.

The shortfalls identified during the assessment had not been highlighted through the service’s own audit systems, indicating these were not effective in identifying risks or driving improvement.

Governance arrangements needed to be strengthened, with both the registered manager and nominated individual working collaboratively to improve oversight, monitoring, and the effectiveness of audit and quality assurance processes.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked in partnership with other professionals and the local community, and shared examples of recent joint working with a local children’s home, demonstrating positive engagement with the wider community and a commitment to collaborative relationships beyond the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We saw there were opportunities for learning within the service, and staff demonstrated a willingness to adapt and respond when changes were identified during the assessment. For example, actions and information shared during the assessment were communicated to staff on shift, showing an ability to learn and respond in real time.

However, learning was not consistently embedded into systems and processes. Incidents, accidents, and falls were recorded but were not routinely analysed to identify themes, trends, or learning opportunities. As a result, actions to reduce future risk were not always identified or shared with staff, and learning from incidents was not consistently used to drive improvements in practice.

Quality audits were in place but were not effective in identifying shortfalls or supporting service improvement. Audits did not demonstrate sufficient scrutiny or follow-up action, meaning learning was not consistently captured or translated into meaningful change. This limited the providers’ ability to use information, feedback, and data to support innovation or continuous improvement.