Springfield House Residential Care 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.

This service scored 61 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

There was no effective system to regularly check progress or measure how well the service was improving. This made it harder to know whether changes were working or if further action was needed. Despite this, the management team were visible and had a strong informal oversight of day‑to‑day practice. The provider understood and acted in line with the duty of candour, which is their legal responsibility to be open and honest with people when something goes wrong.

People were treated with kindness and respect. Staff were valued and contributed to the running of the service. It was clear the culture of the service focused on kind and compassionate care for people living in the home.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

We identified some concerns within the service, which are detailed in the Safe domain of this report. The registered manager had not identified some of the issues found during the assessment and told us the recruitment of a team leader and additional training would be completed to address these.

Despite this, staff described managers as committed to ensuring the service provided care from staff that were supported and valued. They said managers were always willing to help. They also highlighted the strong teamwork, which contributed to the support for people living at the home and staff. We observed the registered manager engaging directly with people and staff, reinforcing their visibility in daily practice. Leaders were open, transparent and responsive to feedback we provided.

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

Staff consistently reported they felt able to approach managers with concerns and were confident issues would be addressed.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Management worked to ensure equality and diversity for staff by making policies, support systems and opportunities accessible to everyone. Staff raised no concerns about discrimination in the workplace.

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

Systems intended to oversee the quality and safety of the service were not effective. Governance processes had not identified the concerns found during this assessment. Routine audits and checks were either not completed or had not been used to drive improvement. For example, incidents that met the threshold for safeguarding were not always reported to the local authority in a timely manner, which meant appropriate oversight and external scrutiny were delayed.

Processes relating to mental capacity were not robust. Mental capacity assessments were not consistently decision‑specific. In some cases, assessments for 1 decision also included other unrelated decisions that may have restricted a person’s liberty. Where restrictions had been applied, there were no individual capacity assessments to support these decisions. These issues had not been recognised because there was no effective audit system. As a result, the provider had not ensured staff had the necessary training or competency to complete assessments in line with the Mental Capacity Act.

The provider acknowledged some care plans and risk assessments may have been out of date due to staffing vacancies. There was no clear system to support the manager or staff in identifying which documents required updating when a person’s needs changed. This meant the service could not be assured documentation consistently reflected people’s current support requirements.

The provider had not consistently submitted statutory notifications to CQC as required by law. This further demonstrated gaps in governance, oversight and regulatory compliance.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The service worked effectively with health colleagues to ensure people’s needs were recognised and understood. Information was shared promptly and appropriately with GPs and community services and advice provided was acted upon.

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. They did not always actively contribute to safe, effective practice and research.

The provider’s systems for monitoring quality and driving improvement were not fully effective. The arrangements had not identified several issues found during this assessment. This limited the service’s ability to recognise shortfalls and take timely action to improve outcomes for people.

Processes to support continuous learning from incidents were not consistently embedded. It was not always clear whether appropriate actions had been taken in response to incidents. Care plans were not consistently updated to reflect changes or provide sufficient detail. Although accidents and incidents were recorded, there was no structured analysis to identify themes, trends or opportunities to prevent future occurrences. While the manager collected some basic data, this information was not used proactively to support learning or reduce potential harm.

Opportunities for improvement were also missed because feedback from people, relatives and staff was not explored in depth. Findings were not consistently analysed or shared, which limited the potential for learning across the service.

The culture of learning and improvement required further development. Although the provider demonstrated a commitment to delivering a quality service and responded promptly when shortfalls were identified during this assessment, systems and processes were not robust enough to ensure sustained, continuous improvement.