CQC report explained · a nursing home
What the CQC found at Springfield Manor Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, suitable risk assessments, safe medicines management and appropriate action after accidents. They were also assured about infection prevention and control.
- Effective?
- Good
- This focused inspection did not assess Effective.
- Caring?
- Good
- This focused inspection did not assess Caring.
- Responsive?
- Good
- This focused inspection did not assess Responsive.
- Well-led?
- Good
- The home had stronger leadership, regular audits and action plans. People, relatives and staff said management was approachable and listened to feedback.
What inspectors found, August 2021
Rated Good after improvement; inspectors found safe care and stronger leadership, while some environmental improvements were still planned.
This was an unannounced focused inspection on 18 August 2021. One inspector reviewed care and medicine records, spoke with people, a relative and staff, observed care, and checked policies and quality records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safer risk assessments, appropriate medicines management, safeguarding procedures and reviews of accidents and incidents. Infection prevention and control arrangements were also found to be suitable.
Leadership and quality checks had improved after a new manager and deputy manager were appointed. People, relatives and staff gave positive feedback about the management. The overall rating had improved from Requires Improvement, and the home was no longer in breach of regulations.
Staffing and prompt support
People and staff said there were enough staff, and inspectors saw people receive help straight away when they needed it.
“During the inspection we saw that where people needed support this was provided by staff straight away.” from the report
Risk management
Care risks such as falls, choking, dehydration and malnutrition were assessed. Staff had guidance on how to reduce these risks.
“Risk assessments provided guidance to staff about the risk, action to take to minimise the risk and how to support people.” from the report
Safe medicines
Medicines were stored securely, labelled correctly and given as prescribed. Staff competency checks were also carried out.
“People were supported to take their medicines as prescribed and medicines were managed appropriately.” from the report
Improved leadership
The new management arrangements brought better oversight of care. Regular audits covered areas such as falls, medicines, infection control and health and safety.
“Since the last inspection a new manager and deputy manager had been recruited and we found the oversight of the quality of care had improved” from the report
Environmental improvements still planned
minorThe home had plans to make the environment more suitable for people living with dementia and to replace furnishings and redecorate. These improvements were not yet complete at the inspection.
“There were also plans to replace furnishings and redecorate the service to create a brighter and fresher environment.” from the report
- 01What progress has been made on making the environment more suitable for people living with dementia?
- 02When will the planned replacement of furnishings and redecoration be completed?
- 03How are staffing levels being adjusted as new people are admitted?
- 04Have the planned electronic medicine administration records been introduced, and how are they checked for accuracy?
- 05How often are risk assessments and quality audits reviewed, and how are outstanding actions followed up?
This was a focused inspection of Safe and Well-led, including infection prevention and control under Safe; the other key question ratings were not assessed in this report. This explanation was written from the published report of 25 August 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.
What inspectors found, February 2021
Requires Improvement; inspectors found ongoing risks with infection control, care records and management oversight.
This was an unannounced focused inspection in December 2020. Inspectors spoke with people, staff and relatives, and reviewed care records, medicines records and management documents.
The home was not always clean. Infection control procedures for visitors were not always followed. Risks such as falls, weight loss and leaving the building were not always clearly recorded or understood by staff.
Medicines were managed safely, and people said they felt safe and found staff kind. There were enough staff overall, but people in their bedrooms did not always receive enough company or prompt call-bell responses.
The overall rating stayed Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home remained in breach of Regulations 12 and 17 because safety systems and management checks were not reliable enough.
Safe medicines
Medicines were organised, given on time and recorded without gaps. Staff knew people's individual medicine needs.
“The management of medicines was safe and organised.” from the report
Kind interactions
People said staff were kind, and inspectors observed caring interactions.
“We observed kind and caring interaction from staff with people.” from the report
Safeguarding improvement
The home had improved enough to no longer be in breach of the safeguarding regulation. Staff had received safeguarding training and understood how to report concerns.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 13.” from the report
Some clinical oversight
Senior staff recorded discussions about clinical needs, and a clinical lead had been appointed to oversee these needs.
“Senior staff recorded regular discussions about people's clinical needs to include wound care, weight loss and falls.” from the report
Infection control
seriousSome areas were unclean, bins had not been emptied and communal shower cleaning was inadequate. Visitor checks to reduce infection spread were not always followed.
“People were not always adequately protected from infection.” from the report
Risks not clearly managed
seriousCare plans did not always accurately describe risks or the support required. Staff were not always familiar with people's risks, including falls, weight loss and leaving the building.
“Risks to people were not always managed safely.” from the report
Weak management checks
seriousAudits failed to identify important problems with cleanliness, infection control, call bells and care plans. This was a repeated breach of the good governance regulation.
“There were insufficient systems in place to robustly check the quality of care.” from the report
Limited contact and communication
needs fixingSome people, especially those spending time in their bedrooms, felt isolated. Relatives said they did not always receive enough information about people's health.
“We received feedback from people that they felt isolated in their rooms” from the report
Call-bell response
needs fixingInspectors found that some people waited for their call bells to be answered, and recent call-bell audits had not been carried out.
“Call bell audits were not taking place despite, according to a staff meeting in September 2020, a concern being raised about the functionality of the call bells.” from the report
- 01What has changed since the inspection to make sure care plans accurately record risks such as falls, weight loss and leaving the building?
- 02How are cleaning, hand hygiene and visitor infection checks now monitored and recorded?
- 03How quickly are call bells answered, and are response times now audited?
- 04How do you now collect and act on feedback from residents, relatives and staff?
- 05How will relatives be kept informed about changes such as weight loss, incidents or other health concerns?
This was a focused inspection of Safe and Well-led, including infection control; the other key-question ratings were not given in this report and the overall rating remained Requires Improvement. This explanation was written from the published report of 10 February 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 Manor Nursing Home
8 rated inspections over 7 years: the service has improved, from Inadequate to Good.
- August 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Springfield Manor Nursing Home →
- February 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Springfield Manor Nursing Home →
- August 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- October 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- September 2018Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2017Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2015Goodup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015InadequateSafe: Requires improvementEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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