CQC report explained · a residential care home
What the CQC found at Springfield
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People received their medicines as prescribed and staff managed falls and safeguarding more safely. However, some medicines records, care plans and patch application records were not complete or detailed enough.
- Effective?
- Requires improvement
- Staff were trained, supported people to access healthcare and provided person-centred mealtimes. It was not always clear whether people had received enough food and drink, and more work was needed to investigate weight loss.
- Caring?
- Good
- This key question was not inspected during this focused visit.
- Responsive?
- Requires improvement
- This key question was not inspected during this focused visit.
- Well-led?
- Requires improvement
- New management and governance systems had improved oversight, communication and staff support. However, the systems had not identified some shortfalls in medicines and nutrition and hydration.
What inspectors found, June 2022
Requires Improvement; inspectors found better management and staffing, but medicines records and food and drink monitoring were not always reliable.
This was an unannounced focused inspection over 27 and 28 April and 4 May 2022. Inspectors looked at Safe, Effective and Well-led because concerns had been raised about falls, general care, fluids and hydration. They spoke with people, relatives, staff and visiting professionals, observed care and reviewed care and medicine records.
The home had improved since the previous inspection. There was a new management team, more reliable staffing, better systems for recording incidents and fewer falls. Staff understood safeguarding, infection control was effective, and people received routine medicines as prescribed.
Further work was needed. Some medicines guidance and records were incomplete, and records did not always show whether people had enough to eat and drink. The overall rating and all three inspected areas were Requires Improvement. The home was no longer in breach of regulations, but the CQC will continue to monitor it.
Improved management
Relatives and staff reported clear improvements under the new management team. Communication and handovers had also improved.
“People had benefitted from a new management team and investment in new technology.” from the report
Safer staffing
Inspectors found enough staff to meet people’s needs. Agency use had reduced and extra wellbeing staff were available at busy times.
“There were enough staff to meet people's needs. All our observations confirmed there was a safe level of staffing.” from the report
Better falls and safeguarding oversight
Falls were managed safely, their occurrence had reduced, and safeguarding concerns were reported appropriately. Staff knew how to identify and report concerns.
“Incidents and accidents were managed safely. This included improved use of technology to ensure better oversight and analysis of any themes and trends.” from the report
Dementia-friendly mealtimes
People could choose where they ate, including their bedrooms, the lounge or dining areas. Care plans recorded food and drink preferences and support needs.
“Lunch and mealtimes were person centred and dementia friendly.” from the report
Staff training and support
Staff received training, induction, supervision and appraisals. New staff shadowed experienced staff before working unsupervised.
“New staff received a structured induction program and completed a period of shadowing with an experienced staff member before they began to work unsupervised.” from the report
Incomplete medicines records
needs fixingSome guidance for creams lacked detail, some as-needed medicine protocols were out of date, and records did not always explain why medicines were given or their outcome.
“Records to guide staff in the application of topical medicines were in place; however, some lacked detail on where the creams were to be applied.” from the report
Food and fluid records
needs fixingStaff did not always record what people had eaten and drunk. More work was needed to investigate the reasons for weight loss and make sure action was taken.
“It was not always clear whether people had received enough to eat and drink. Staff did not always record this information.” from the report
Governance did not find all shortfalls
needs fixingAlthough new checks and technology had improved oversight, audits had not identified all the medicines and nutrition problems found during the inspection.
“Whilst improvements had been made to the provider's governance systems, these had not identified shortfalls in the management of medicines and nutrition and hydration.” from the report
One care plan needed updating
needs fixingOne person was supported by two staff to stand, but their care plan said one staff member was needed. The manager updated the file after inspectors raised this.
“A third file needed updating. We observed one person at medium risk of falls being supported by two staff to stand however, the care plan recorded the person required one person.” from the report
- 01How do you now check that topical medicine instructions say exactly where creams should be applied?
- 02How do you make sure out-of-date as-needed medicine protocols are removed and that staff record the reason and outcome when these medicines are given?
- 03How are food and fluid records checked each day to confirm people have had enough to eat and drink?
- 04How do you investigate weight loss and make sure actions are completed?
- 05What changes have been made to governance checks so they identify medicines and nutrition problems sooner?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the overall rating used the ratings from this visit and the previous inspection. This explanation was written from the published report of 16 June 2022 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, March 2021
Rated Requires Improvement; inspectors found unsafe risks, medicines and staffing problems, and weak checks on quality.
This was a planned inspection. Inspectors visited on 13 and 18 January 2021, spoke with people, relatives and staff, and reviewed care records, medicine records, recruitment files and quality checks.
They found that risk assessments did not always describe people's risks properly. Some incidents were not reported, lessons were not always learned, medicines were not always managed safely, and there were periods when staffing did not meet people's needs.
The home was clean and staff used protective equipment. People said they felt safe, and recruitment checks were considered robust. However, the overall rating fell from Good at the last inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement.
People felt safe
People told inspectors that they felt safe living in the home.
“People told us they felt safe living at Springfield.” from the report
Recruitment checks
The provider had checks in place to assess whether staff were suitable to work in a care setting.
“The provider had robust recruitment checks in place to ensure staff were suitable to work in a care setting.” from the report
Clean environment
Inspectors found the home clean and tidy, and saw staff using protective equipment during personal care and food handling.
“The home was clean and tidy.” from the report
People's views were sought
Meetings were held with people, relatives and staff to communicate changes and gather feedback.
“Meetings were held with residents, relatives and staff to communicate any changes within the home and gather feedback from people.” from the report
Risk management and safeguarding
seriousSome safeguarding incidents were not reported. Risk assessments lacked important information, repeated falls were not effectively managed, and some required observations were not completed.
“Safeguarding allegations and incidents had not always been reported to CQC or the local safeguarding team.” from the report
Medicines
seriousMedicine patches were not always recorded properly, some medicines were out of stock, and some instructions for medicines given when needed were not detailed enough.
“Medicines were not always available to give as they were out of stock.” from the report
Staffing levels
seriousThere were periods when areas were left unsupervised. The staffing tool did not take account of people needing two staff for personal care.
“There were not always enough staff to meet people's needs.” from the report
Weak quality oversight
seriousAudits and monitoring did not identify the problems found by inspectors. There was no overall action plan, and some care and fluid records were incomplete or inaccurate.
“There was no overall action plan within the home to address ongoing concerns such as unwitnessed falls or improvements identified within audits.” from the report
Restrictive practices
seriousSome people's rooms were locked during the day without evidence that a best-interest decision had considered less restrictive alternatives.
“There was no evidence of a best interest decision being made to determine whether other alternatives could have been considered rather than using restrictive practices.” from the report
- 01What action has been taken to prevent repeated falls and make sure risk assessments contain the right information?
- 02How do you make sure all medicines are in stock, patches are recorded correctly, and 'when required' medicines have clear instructions?
- 03How many staff are on each unit at different times, and how do you cover people who need two staff for personal care?
- 04What action plan is now in place for falls, care records, medicine management and other inspection concerns?
- 05How do you make sure any restriction, such as locking a person's room, is properly considered and recorded?
This planned inspection covered the overall quality of the service but only gave ratings for Safe and Well-led; the other three key questions were not rated in this report. This explanation was written from the published report of 17 March 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 Springfield
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- June 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017Requires improvementstayed Requires improvementSafe: InadequateEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 January 2011.
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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