Springfield Nursing Home

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 good. At this assessment the rating has changed to 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 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although the provider had a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement, this was not always followed or considered by staff.

We observed mixed morale amongst the staff. Some staff appeared motivated and demonstrated a keenness to respond to people in a kind, caring and supportive way. However, other staff appeared disengaged and despondent, for example, were seen stood chatting with each other even when call bells were ringing for long periods and appearing to avoid areas where groups of people were sat.

Some staff spoken with described their frustration and concerns that people do not always get what they need. A staff member said, “I’m fed up with telling them [other staff] about how [name of person], would eat more if given [types of food] and support [person] with eating, but they don’t listen.” Another staff member said, “It’s so stressful, I rush around and really want to give people time, but other staff just ignore them which means some of us [staff] are trying to do everything.”

The management team were aware of mixed staff morale prior to our assessment and had plans to address these concerns.

Staff members also acknowledged the manager was trying hard to address staff morale and shortfalls. One staff member said, “[Name of manager], is lovely, they are really trying to change things and are giving it 100 percent.” Whilst we received positive feedback about the managers approach, we were informed this manager had left the service shortly after the inspection.

The provider did not always have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge and experience to lead effectively.

The concerns identified on this assessment as detailed throughout this report had not been identified or effectively managed until highlighted by inspectors.

The provider was in the process of recruiting an additional deputy manager with a clinical background to enhance clinical oversite within the service. Throughout the assessment the management team were open and honest. They demonstrated they were dedicated and passionate about their roles and wished to make the required improvements to the service that we had identified to ensure people had a good quality of life and received safe, effective and high-quality care.

We received mixed views from people, relatives, professionals and staff about the overall running of the service. A staff member said, “[Manager] is trying really hard, I think things will get better.” Another staff member told us, “Things are getting better, I think, [name of manager] does really listen to us, is approachable and is working really hard to change things.” A relative said, “It’s improving – there is a new Manager, they are much better.”

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

People, relatives and external professionals felt able to raise anything with the management team and staff told us the manager would listen to them and described the manager as available and approachable.

Leaders told us they regularly asked for feedback and expected openness and honesty from staff. They were working hard to enhance team approach and responsibility.

Information about whistleblowing was readily available for staff reference as needed.

Although the provider demonstrated they valued diversity in their workforce, they did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We received mixed feedback from staff, whilst the majority of staff told us they could approach the management team at any time and they would listen, they felt they were not always well supported by their colleagues. Feedback included, “It’s always the same staff that do all the work” and “I love working here and love the people, but we don’t get handovers and don’t always know what we are doing, we [staff] don’t all help each other and we aren’t a team.”

The management team were aware of these issues and were working to address these by working more closely with staff, strengthening staff allocation and encouraging staff to take ownership and accountability of their actions.

Leaders had policies and training in place to support equality, diversity, and inclusion and where required, reasonable adjustments were implemented appropriately for staff.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems were not robust to assess, monitor and improve the quality and safety of the service to ensure regulations were met. We found breaches of regulations.

The auditing systems and processes in relation to care plans and record keeping had not identified the full extent of the shortfalls we found in this area. Monitoring systems were not effective in identifying gaps in practice. For example, audits failed to detect gaps in repositioning, poor fluid and bowel monitoring, and unsafe food consistency being provided. The systems had not identified there was a lack of comprehensive, detailed records, including care plans and risk management plans to provide staff with sufficient guidance on how to meet people’s individual needs and provide them with safe, effective and responsive care. Therefore, we could not be confident that had we not completed this assessment these shortfalls would have been identified which would have resulted in continued unsafe care being provided.

The providers systems had failed to identify communication systems between units and across shifts were also ineffective, leaving staff sometimes unaware of significant events, such as hospital admissions and appointments or changes in people’s care needs.

Systems had failed to identify the management of learning, improvement, and risk was ineffective. For example, deterioration in people’s physical wellbeing was not identified or escalated effectively. This meant people would not always receive care, support and treatment in a timely way.

Where some shortfalls had been identified by the management team prior to the assessment visits, actions taken to address these had not always been effective. For example, the provider was aware of the delays in call bell response times and had taken actions to address these including, ensuring clearer staff allocation. Although this has resulted in slight improvements and was an ongoing process, significant delays in call bell responses remained, placing people at continued risk of significant harm.

The shortfalls we identified were brought to the attention of the management team who agreed action would be taken to address these issues. Shortly following the completion of the assessment visits, we received correspondence from the management team detailing actions they had and planned to take to address the concerns to ensure the ongoing safety and wellbeing of people.

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 management team expressed an open positive attitude to receiving support and understood how and where they could access support. They had developed links with many local community organisations including schools, activities and religious organisations and people were supported to engage in a range of local community events.

Feedback from healthcare professionals reflected a recent improvement in collaboration with the service and attributed these improvements to the availability and proactiveness of the new manager.

People and relatives were involved in their care. Support groups and people and relatives’ meetings were held frequently. These meetings were used not only to share and receive feedback about the service and care but also as a social event, for example, allowing people and families to socialise together while sharing cheese and wine. Actions taken in response to feedback was shared in a number of ways including, a ‘you said’ we did’ board and newsletters.

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.

Although the provider encouraged a culture of continuous improvement by ensuring systems were in place to promote continued oversight of the overall governance of the service, these systems were not always used effectively.

Throughout our assessment we saw continued concerns relating to re-positioning, recognising deterioration and ensuring people’s basic care needs were consistently met. Therefore, concerns were not always captured, analysed and information from incidents was used to support learning, improvement and innovation. This meant opportunities to identify patterns, learn from incidents and make improvements were limited, reducing the services ability to enhance the quality and safety of care for all people living at Springfield Nursing Home.

The management team provided us with records of staff having completed mandatory training and training relevant to their role. However, some of the staff we spoke to, feedback we received from relatives and professionals and from our observations we were not assured all staff understood the training they had received or how to put the training into practice.

The leaders had recently implemented a ‘Learning and Improvements Committee’ within the organisation. The aim of this committee was to study patterns of issues across the group and make recommendations on how to break the cycle and to discuss best practices and share with the relevant departments. This committee was currently in its infancy and required time to be embedded into practice.

The management team were responsive to our concerns and conducted internal investigations of our concerns, completed, reviewed and updated assessments of people’s needs, their care records and risks assessments, implemented new systems and reviewed staff skills and abilities, taking additional action where required. The management team demonstrated they were committed to making the necessary improvements.