Springfield Nursing 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 assessment we rated this key question good. At this assessment 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.

We found a breach in regulations in relation to safe care and treatment.

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. Lessons were not always learnt to continually identify and embed good practice.

Although the provider had systems and processes to support a proactive and positive culture to help ensure lessons were learnt to continually identify and embed good practice, we found these were not used effectively and robustly.

Prior to our assessment we received concerns from health and social care professionals and commissioners about specific shortfalls in the care provided to people. These concerns had also been shared with the provider and management at the home prior to our assessment visits. Throughout our assessment we continued to find shortfalls in safe care and treatment and identified that although some actions had been taken to investigate and address specific concerns these had been done so in isolation. This meant people remained at continued risk of harm. This was discussed in detail with the manager and providers representative who took immediate action by conducting full clinical reviews of people living at Springfield Nursing Home to help ensure risk controls, care planning and all aspects of care provided was appropriate and effective to ensure safety and wellbeing.

The provider completed statutory notifications in line with their legal requirements and regulation. The manager carried out regular supervision, appraisals and team meetings which gave staff opportunities to reflect on practice and discuss learning.

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 management team showed clear understanding of the company’s policy and procedure, they were aware they would only admit people to the service after completing a full assessment. This meant people had robust assessments completed before they moved to the service.

If a person needed to be admitted to hospital or transferred to another service, information about their medicines and health and care needs would be provided.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

We received mixed views from people, relatives and professionals about the safety of the care provided. A number of people and relatives described how people were put in positions where they placed themselves at risk of avoidable harm or injury due to not receiving the support they required in a timely way. For example, accessing toileting facilities without the required support. However, other people described how they felt safe at Springfield Nursing Home.

The processes to ensure safeguarding concerns were identified, investigated and acted on in a timely way were not robust. Where potential safeguarding concerns had been identified, these had not always been fully investigated, including the completion of action plans and root cause analysis to establish potential causes, themes and trends and mitigation to prevent future incidents. Throughout our inspection, we found instances of people being placed at risk of avoidable harm and potential neglect, these had not all been identified and acted on in a timely way.

Staff had received training in safeguarding and were able to describe types of abuse and what action to take if they had any concerns. There were safeguarding and whistleblowing policies which gave staff clear guidance to follow in the event they needed to refer any concerns to the local authority. However, from our finding further described throughout this report we could not be assured all staff acted in accordance with this training.

Mental Capacity Act (MCA) assessments, best interest decisions and Deprivation of Liberties Safeguard (DoLS) applications had been completed where required which meant we were assured staff protected people's human rights in line with the MCA. The management team kept a record of DoLS applications and authorisations, and this was regularly reviewed to make sure authorisations were current.

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

People’s care plans were not always completed accurately, sometimes contained contradictory information and lacked detail around specific conditions. For example, including but not limited to, risks of constipation, management of breathlessness for people with conditions relating to breathing and pressure area care. This increased the risk of people not receiving the care they required in a timely way placing them at risk of a deterioration in their health and wellbeing.

People had been assessed as requiring regular repositioning to mitigate the risk of skin damage. However, on review of some people’s repositioning records we could not be assured they were repositioned as required.

People had been assessed as requiring food which needed to be modified to a specific consistency to reduce the risk of choking. However, we observed food provided had not been modified in line with people’s assessed need. We discussed modified diets with staff including those who worked in the kitchen and none of these staff were aware of these people’s need for modified diets. When this was discussed with the manager, they told us these people had made an informed choice to continue to eat food at normal consistency. Although the managers comments demonstrated people had been supported to make these decisions, this was not always clear in the care records and staff should have been fully aware of the risks posed to these people while continuing to eat food deemed unsafe. Other mitigations and agreed actions to protect people had not been explored or identified in care plans.

Staff did not always recognise or respond promptly when people’s health deteriorated or identify or act on potential risks. For example, for 2 people we observed they found it difficult to drink independently from the drinking vessels provided. This meant people were at risk of dehydration. Our review of these people’s fluid intake records additionally demonstrated they were not being supported to drink enough in line with their assessed needs.

We identified effective action was not always taken in a timely way when people showed signs of being unwell. This has been further explained in the caring section of this assessment report under responding to people’s immediate needs.

The above concerns were discussed with the management team who agreed to take immediate action to address these.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had created a safe and well-maintained environment. People’s rooms were personalised, and they had the equipment they needed to keep safe. Communal areas were nicely decorated, clean and hazard free. There was an accessible and well-kept garden. There was signage around the home to support people to move around freely and safely.

There were effective arrangements to monitor the safety and upkeep of the premises, and the management team completed regular checks. There were appropriate environmental risk assessments when required, for example, in relation to fire safety. Regular safety audits were completed including for utilities and equipment. Where concerns were identified records of required actions and outcomes were maintained.

There were contingency plans in to be followed during adverse events for example during a power cut or adverse weather conditions.

The provider did not make sure there were enough qualified, skilled and experienced staff who were effectively deployed, to ensure people were prioritised and their needs responding to in a timely way. Staff did not work together well to provide safe care that met people’s individual needs.

We received mixed views on the staffing levels at the home. Some feedback we received from relatives, people and a professional were positive. However, most people, relatives and professionals told us responses to call bells was problematic for them. A person told us, “The other day I got to the point that as my bell didn’t get answered I took myself to the toilet. I knew it was risky but just couldn’t wait any longer.” Another person said, “I have been appalled with the bells, one morning I rang at 6.50 and eventually they came at 7.30, often 10 minutes or more is the norm before someone comes to see you.” A third person described how they rang their call bell once when they felt unwell. They said, “I rang and rang, no-one came.”

Relatives’ comments included, “[Person] gets frustrated having to wait for staff to answer her bell, so she goes to the toilet on her own at night” and “Sometimes the response to the call bell is 15-20 minutes.”

We reviewed call bells records and could not be assured there was always enough staff who were appropriately deployed to efficiently meet people’s needs. We identified call bells were not always responded to promptly with significant delays at times. For example, over a 72-hour period call bells sounded 1199 times. Of these call bells, 378 took longer than 10 minutes to be responded to, with 51 taking between 20 to 25 minutes, 31 taking between 25 to 30 minutes and 14 taking over 30 minutes.

Call bell response times were discussed with the management team who were aware of this issue and were working to address this. Although the manager team were able to demonstrate there has been some improvement in the average call bell response time over the last few weeks we found, there continued to be significant delays for staff responses to call bells. This meant people did not receive the care and support they required to keep them safe in a timely way, particularly where people may need timely assistance to ensure their ongoing safety.

Staff described the poor call bell response times being the result of lack of staff, organisation in relation to the allocation of staff and individual staff member’s attitude. A staff member said, “We need more organisation, but we also need more staff. There are a lot of staff stood talking while bells are ringing and they ignore them.” Another staff member told us, “Lots of staff ignore the bells, it’s not fair on the people or the other staff and it really upsets me. I will often ask for help but am ignored, we aren’t a team.”

Staff received regular training and supervision to ensure they had the knowledge and skills for their role. The management team monitored staff compliance to ensure they were up to date with training and supervision. Staff were positive about the training provided. However, from our discussions with staff and our review of records we were not assured all staff had the skills and ability to recognise when action was needed to address presenting health needs. Nearly all feedback from healthcare professionals raised concerns about timely and effective responses to people’s needs. A healthcare professional said, “I feel that staff are significantly lacking confidence in their own skills - both the carers and the nursing staff. Often there is significant disparity in the skills needed and staff will wait for external professionals to be on site for tasks to be done either due to lack of confidence in their own skills or the assumption that the patient is 'a rehab patient' thus it isn't their responsibility. There have been episodes of patients becoming medically unwell as staff are not escalating concerns in a timely way.”

Staff were safely recruited, and checks were carried out before they started work to reduce the risk of unsuitable staff being employed.

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.

During our assessment visits we found the home to be generally clean, tidy and maintained to a good standard.

Staff completed infection prevention and control (IPC) training and understood their responsibilities. IPC audits were regularly completed to help detect and minimise the risk of the spread of infection. Staff confirmed they had access to personal protective equipment (PPE), when needed and we observed staff using this appropriately.

The management team understood the actions they should take should there be an infectious disease outbreak at the home.

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

Medicines were not always managed safely. While storage arrangements were secure and temperature checks were completed, some protocols for medicines taken ‘as required’ (PRN) lacked detail on when medicine should be given, specific doses, and potential actions to take prior to medicine being administered. This meant people were at risk of not receiving medicines they needed when they needed them, receiving incorrect doses, or their health needs not being escalated.

Medicine stock records contradicted the medicine stock on site. Therefore, we could not be assured people had always received their prescribed medicine safely.

The management team took immediate action to address these issues.