Springfield Care Home

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 inspection we rated this key question good. At this inspection the rating has changed to 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 people’s safe care and treatment.

This service scored 41 (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 proactive and positive culture of safety. Lessons were not learnt to continually identify and embed good practice.

There was a lack of effective systems in relation to reporting and investigating incidents. This included a lack of systems to identify any learning and to share this with the wider staff team. Current processes were not effective or robust in learning from incidents and sharing learning with all staff. In addition, there was a lack of understanding around the importance of having effective systems in place and any current audits had not identified this gap in learning.

Not all incidents and accidents were reported. For example, we saw a mark on one person’s hand and asked how this had occurred. There was no record of the incident having been reported. When incidents and accidents occurred, learning from these was not shared formally with all the staff team. Additionally, incident forms did not consistently include information about steps taken to reduce the risk of recurrence. The manager and staff told us that learning was shared during handover, but this was not formally recorded and meant that new staff, or those staff not at work, would not always be made aware. There were no minutes of staff meetings in place, which meant we could not be assured if learning was shared in these forums either. Staff told us they were informed about incidents during handover, but they were unsure how they would know about incidents that occurred if they had been on leave for example.

Although analysis of falls in the service had begun, there was limited information recorded. This meant it was difficult to assess how beneficial the analysis would be in preventing further falls going forward.

After the inspection the manager told us they had put in place a process to share learning with staff. This was formal and staff were required to sign to confirm they had read the information. The improvements made needed to be embedded into practice and sustained.

People’s relatives told us they were informed if their loved one had an accident, such as a fall. A relative said, “[Person] had one fall. The service phoned me and checked [person] out and [person] was completely fine.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Records showed the service worked with healthcare partners such as the GP and community nurse team. However, we received mixed feedback from professionals on how effective this was. Some health professionals told us they felt that their advice and professional judgement was not consistently followed, whilst others told us it was. For example, some health professionals told us they were not confident staff followed their advice or plans. They said, “We give them good advice, and we provide them with care plans, but not sure they follow them. We do reiterate our advice to them, but we don't feel confident it is followed.”

Other health professionals told us staff always provided them with information about people when asking for them to be reviewed. For example, one professional said, “I get given all appropriate information prior to visits such as observations, weekly or monthly weights depending on the individual patient’s needs. Their computer records and notes are thorough and up to date. They follow plans I make carefully and communicate well between staff on different shifts/days.”

During the inspection we saw there was mixed communication between the management team and one of the community teams. Following the inspection we were told by the external agencies that regular multi-disciplinary team meetings had been put in place to address these issues.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately.

There was a lack of clarity within the management team of what constituted a safeguarding referral and when a notification to the commission was required. Incident forms were not consistently completed for all injuries. We were told the threshold for completing incident forms was if an injury was a result of an unknown cause. This meant there was no clear view of how many incidents had occurred. Because other incidents had not been consistently reported, there was a risk any trends might not be identified or escalated within the service.

Staff had been trained in safeguarding and told us they understood their responsibilities to keep people safe. A staff member said, “If I saw some bruising or a skin tear, I would tell the team leader, and they would take a photo. We must report it because we don’t know what's happened.” Although staff were reporting concerns, onward reporting was inconsistent.

Despite this, people and their relatives told us they felt safe living at the service. Comments included, “They are all superb here, all very good every one of them. They will help with anything and look after us,” and, “I can relax now that [person] is here, whereas before, I was always on call, and just a bit worried about [person].”

We observed staff supporting people using the hoist. We saw staff talked the person through the process, did not rush the person, and supported them by holding their hand to reduce any anxiety.

Staff did not always provide care to meet people’s needs that was safe and supportive.

Although risk assessments had been carried out, when risks to people were identified, care plans did not consistently provide clear guidance for staff on how to reduce the risks. For example, when people were assessed as being at risk of skin damage, care plans did not always inform staff about how often people should be supported to change position, or the signs to be aware of. One person’s position change records we looked at, showed one person with a pressure wound had been in the same position for over 7 hours at a time on 4 consecutive days. There was a risk the person’s pressure wound might deteriorate if pressure wasn’t relieved by changing their position. The lack of guidance in care plans around position changes, meant it was unclear how staff would know when to support people to move.

Another person’s care plan contained contradictory information on whether they had a pressure sore. Following a change in the person’s skin condition, the care plan and relevant risk assessment had not been updated to reflect the change in the person’s needs.

Staff knowledge around skin integrity was not consistent and although training records showed staff had been trained in this area, it was unclear how staff had been assessed for their knowledge following the training. This meant there was a risk staff might not understand the importance of monitoring people’s skin or when they needed to escalate concerns around people’s skin. Some health professionals we spoke with also raised concerns about the lack of staff knowledge.

Some people had been assessed as being at risk of choking, but care plans did not inform staff of all the steps they should take to prevent a choking episode, or what to do if someone did choke. Risks in relation to high and low blood sugar levels for people with diabetes, had been assessed but the signs of high and low blood sugar staff should be aware of, were not documented. This meant there was a risk staff might not know when to escalate concerns.

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.

During the first 2 days of the inspection, we saw a red plastic barrier screen at the bottom of the main stairwell. However, there was a gap between the barrier and bottom of the stairs which people could get through. There was a risk that people could access the stairs unsupervised. We discussed this with the management team and were told that it was under review. On day 3 the barrier had been changed and access to the staircase was now closed off.

Moving and handling equipment checks were not robust. We saw hoists had been padded with bandages which raised concerns about poor moving and handling techniques. This had not been identified during audits. Wheelchair checks had been carried out, but the forms in use were inconsistent. Some forms included checks for tyres and brakes but not all. It was unclear why some columns were missing from some forms. This had not been identified during the checks, and the lack of provider oversight meant the inconsistencies had not been noted.

A garden risk assessment dated 01 May 2025 stated “Flammables – no flammable products to be stored on site and if any are used to be removed from site afterwards.” We saw there was a barbeque in the back garden, and the door of the barbeque stand was unlocked and contained sharp tools and lighting gel. We informed the management team, and this was removed.

Some first aid kits contained out of date equipment, some of it was over a year old. Biohazard equipment packs were also out of date. The risk assessment in place stated these should be checked monthly. The system in place was not effective and did not identify this shortfall.

We saw that staff could log any maintenance issues for the attention of the maintenance team. However, the log showed issues had been ticked only. This did not provide evidence of how the issue had been resolved, and any action taken. Safety checks on gasand electricity were carried out by external professionals. The service had been assessed for fire safety, and we saw a further assessment which confirmed recommended actions had been completed. Regular fire drills and practice evacuations were carried out, during the day and at night.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective training.

Training records did not always show that staff were trained and competent to carry out their roles. Although care staff had watched online videos in relation to skin and pressure care, knowledge around how to prevent skin damage was inconsistent. Care plans did not inform staff of the support they should provide and records did not show people had their positions changed regularly to prevent skin damage. Staff we spoke with were not always clear about their roles and responsibilities. Health professionals we spoke with also raised concerns about staff training in this area.

At the last inspection, not all staff understood diabetes management. At this inspection, records showed not all staff had been trained in diabetes. This meant there was a risk staff would not be able to recognise, act on or escalate concerns about high or low blood sugar levels. The manager told us senior staff had completed training and care staff knew to escalate concerns to them. However, without diabetes knowledge it was unclear how care staff would know when they needed to escalate concerns.

Manual handling training was provided, and we saw evidence of how staff were assessed as competent. Some health professionals raised concerns about moving and handling techniques used. A professional said, “Staff don’t always seem to understand the importance of repositioning.” When we asked care staff about manual handling they told us they had been trained and understood why people needed to be supported to change position safely. A staff member said, “I would stop staff if I saw them doing something I wasn’t happy with and I have done in the past."

People told us there were enough staff on duty and people’s relatives agreed with this. Comments included, “There’s lots of staff, lots of different uniforms. Several staff have been there for a long time. That tells me something” and “Yes, there’s always plenty [of staff] about and someone to talk to if you need to.” During the inspection we saw staff were visible and call bells were answered quickly. Staff we spoke with told us they felt there were enough of them on duty. A staff member said, “I have no concerns about staffing levels. It’s the same at weekends. [The manager] is very good; they will always get agency or other help in if we need it.”

Safe recruitment processes were followed. Staff received regular supervisions. A staff member told us, “We have supervisions every 3 months. [The manager] is very hot on that.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

In the main, the home was visibly clean and well maintained, although we did note some areas where improvement was needed. For example, some furniture edging was worn and some flooring in various areas of the home was cracked and needed replacement. The manager explained these were areas due to be refurbished.

Infection prevention control procedures were not always followed. For example, we saw mops placed directly on the floor in the laundry room, instead of being hung to dry effectively and reduce the risk of cross contamination. Some pressure relieving cushions were ripped which meant staff would not be able to clean them effectively. Although there were some audits and checklists in place, there was no apparent oversight to ensure these were being completed regularly and effectively. For example, we noted some gaps on checklists with no explanation given.

Although infection prevention and control audits had been completed, they did not correspond with some of our findings during the inspection. For example, the latest audit dated September 2025, in the section for spillage kits being checked and in date was marked “yes.” The section for manual handling equipment being clean was marked as “yes” despite the hoists having padded bandaged areas which could not be cleaned. The section for carpets being clean and stain free was also ticked “yes” but we saw at least one bedroom carpet that was badly stained and which we had been informed was due for replacement because of the condition it was in.

People told us they were happy with the cleanliness. A relative said, “It’s very clean. I’m always having to lift my feet up when I visit as they’re forever cleaning up. There’s always someone to clean up spills.” The housekeeping team was on duty seven days a week. Cleaning chemicals were safely locked away when not in use by staff.

Staff told us they had been trained in infection prevention and control and knew when and how to apply personal protective equipment (PPE) and when and how to safely discard it after use. There was enough PPE available for staff to use.

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

Medicines were not always managed safely. One room where medicines were stored was open and unlocked and a cupboard storing additional stock of medicines was unlocked within the room. Staff told us the door to the room had a broken lock, and this was replaced after we raised it, but it had not been rectified earlier.

Thickener was not consistently safely stored. Although staff told us the thickener was kept in a locked storage box, the box was unlocked and accessible when we looked.

There were issues noted with record keeping. The provider’s medicines policy was not consistently being followed by staff in several aspects of medicines management. Records showed homely remedies had been given to staff, which was not in line with the provider’s medicines policy. Protocols for the use of additional medicines were not always in place. When they were in place they did not consistently describe when or why people might require them, or steps staff should take before administering them. The temperature of medicines storage areas was monitored. However, medicine fridge temperatures had not been monitored in line with guidance because the minimum and maximum temperatures had not been recorded. Staff told us there was a known issue with the fridge which is why the minimum and maximum temperatures had not been recorded, but no action had been taken. During the inspection, a new fridge was ordered. Transdermal patch records did not consistently show patch placement was rotated in line with manufacturer’s guidance. Additionally, we noted staff had not always signed for medicines with their full name which is not good practice.

Topical creams and lotions were stored safely and had been dated when opened. This meant staff would know when the product had expired. However, we also saw 1 person’s eye drops and another’s person’s medicated cream had expired but had not been discarded by staff when the person no longer required them.

Although medicine audits had been carried out, they had not identified the issues we noted.

Medicines were administered by staff who had been trained and assessed as competent. People and their relatives told us they received their medicine on time and had no concerns about how their medicines were managed. A relative said, “I was worried as [person] used to have injections, so I talked to the manager, and they talked to the GP and [person] now has tablets which is much better. It was a good result.”