We carried out a review of the data available to us about Springwood on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Springwood, you can give feedback on this service.
People’s experience of using this service and what we found
During the inspection we found windows had restricted openings and were suitably robust. The provider had completed regular environmental risk assessments to assess the risks posed by the premises and where people had been identified at risk of falls adequate control measures had been put in place.
We have made a recommendation about the management of risks of associated with falls from windows or height.
The provider had effective Infection prevention and control systems in place. The layout of the premises, use of space and hygiene practice promoted safety. People were supported to maintain contact with their family and friends, and they were welcome to visit the home.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 3 December 2020).
Why we inspected
The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of people falling from height. This inspection examined those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We found no evidence during this inspection that people were at risk of harm from this concern.
Please see the safe section of this full report.
We found the following examples of good practice.
¿ People were protected against the risk of infection.
¿ The home had robust systems in place to support relatives to visit their family members, minimising the risk of infection. Visits were facilitated in the outside grounds of the home in a designated pod. The pod was segregated with separate entrances for people and their relatives. This was heated and thoroughly cleaned between visits. The only exceptions to these arrangements were visits to people placed on end of life care. Visits took place by prior arrangement and PPE was worn.
¿ The registered manager and staff had considered how to prevent social isolation during the pandemic. They had put in place befriending services and additional activities to ensure peoples well-being was mainained.
¿ The provider had regularly updated policies and procedures to ensure they included changes and best practice guidance in relation to COVID-19. Staff we spoke with were knowledgeable about the updates and were working in line with them.
¿ We observed staff changed PPE, when appropriate, and washed and sanitised their hands. Staff changing facilities had been provided to minimise the risk and spread of infection.
¿ Tests for COVID-19 were being carried out in line with guidance, where possible.
¿ The premises were clean. There was a cleaning schedule in place and adequate cleaning hours to ensure it was maintained. Additional cleaning of high use areas had been implemented, including door handles, and hand rails. We identified some areas required attention. For example, bath chairs, microwaves and dishwashers required further cleaning. The registered manager addressed this immediately. They also amended the audits to ensure they were not missed.
¿ Staff had completed training in infection control, COVID-19 and how to put on and take off their PPE. Staff were frequently briefed about changes in government advice that impacted on their role. Staff we spoke with confirmed this.
¿ Risk assessments were in place to consider and reduce any impact to people who used the service and staff who may be disproportionately at risk of COVID-19. These included Black, Asian and Minority Ethnic groups (BAME), people with learning disabilities and people with dementia.
Further information is in the detailed findings below.
Springwood can accommodate up to 38 people that require accommodation and personal care, some of whom are living with dementia. The home is purpose built over three floors and each floor has communal lounges and dining areas. At the time of our inspection, there were 36 people using the service.
At our last inspection in February 2016, we rated the service good. At this inspection, we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.
There was a manager at the service who was registered with the CQC. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People living at Springwood told us they felt safe. There were enough staff available to care for people safely and we observed staff providing care to people in a timely way. We saw staff were kind and caring. They treated people with dignity and respect.
We saw the service used effective recruitment procedures, which helped to keep people safe. Staff completed a thorough induction and received regular training to support them in their roles. Staff said they had been provided with safeguarding vulnerable adults training so they had an understanding of their responsibilities to protect people from harm.
There were procedures in place to support the safe management and administration of medicines.
People’s needs were assessed to ensure they received the correct level of care and support. People were supported to have maximum control and choice over their lives and staff supported them in the least restrictive way possible. Policies and systems in the service supported this practice.
People’s healthcare needs were met. They had access to community based healthcare professionals, such as GPs, and they received medical attention when needed.
The registered manager completed regular audits of the service to make sure action was taken and lessons learned when things went wrong. This meant systems were in place to support the continuous improvement of the service. People living at Springwood and their relatives had confidence in the management of the service.
People living at Springwood and their relatives were all very positive about the care they received. They spoke very highly of the carers employed at the service.
Further information is in the detailed findings below.
There was a manager at the service who was registered with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
Our last inspection at Springwood took place on 1 July 2014. The home was found to be meeting the requirements of the regulations we inspected at that time.
This inspection took place on 11 February 2016 and was unannounced. This meant the people who lived at Springwood and the staff who worked there did not know we were coming. On the day of our inspection there were 35 people living at Springwood.
The registered manager was not present during our inspection visit and the deputy manager was in charge of the home.
People spoken with were positive about their experience of living at Springwood. They told us they felt safe and staff were “Smashing” and “Lovely”. They told us they could talk to staff and if they had any worries or concerns they would be listened to.
Relatives spoken with had no concerns regarding their relative’s care. They told us they knew staff well and they were always kept them up to date with any news.
Healthcare professionals spoken with also made positive comments. Comments included, “The staff are very caring” and “This is a really good home.”
We found systems were in place to make sure people received their medicines safely.
Staff recruitment procedures were thorough and ensured people’s safety was promoted.
Staff were provided with relevant induction and training to make sure they had the right skills and knowledge for their role. Staff understood their role and what was expected of them. They were happy in their work, motivated and confident in the way the service was managed. The service followed the requirements of the Mental Capacity Act 2005 (MCA) Code of practice and Deprivation of Liberty Safeguards (DoLS). This helped to protect the rights of people who may not be able to make important decisions themselves.
People had access to a range of health care professionals to help maintain their health. A varied and nutritious diet was provided to people that took into account dietary needs and preferences so their health was promoted and choices could be respected.
People living at the home, and their relatives said they could speak with staff if they had any worries or concerns and they would be listened to.
We saw people participated in a range of daily activities both in and outside of the home which were meaningful and promoted independence.
There were effective systems in place to monitor and improve the quality of the service provided. Regular checks and audits were undertaken to make sure full and safe procedures were adhered to. People using the service and their relatives had been asked their opinion via questionnaires, the results of these had been audited to identify any areas for improvement.
We gathered evidence against the outcomes we inspected to help answer our five key questions; is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?
Below is a summary of what we found.
If you want to see the evidence supporting our summary please read our full report.
Is the service safe?
People supported by the service, or their representatives told us they felt safe.
People told us they felt their rights and dignity were respected.
Systems were in place to make sure managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.
We found risk assessments had been undertaken to identify any potential risk and the actions required to manage the risk. This meant people were not put at unnecessary risk but also had access to choice and remained in control of decisions about their care and lives.
The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made and how to submit one. This meant people would be safeguarded as required.
The service was safe, clean and hygienic.
Is the service effective?
People's health and care needs were assessed with them and their representatives, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required.
Staff were provided with training to ensure they had the skills to meet people's needs. Staff were provided with formal individual supervision and appraisals to ensure they were adequately supported and their performance was appraised. Team leaders had developed a matrix and schedule for staff supervisions to address some identified gaps. This meant staff would be provided with supervision at an appropriate frequency. Managers' were accessible to staff for advice and support.
Visitors confirmed they were able to see people in private and visiting times were flexible.
Is the service caring?
We asked people using the service and relatives for their opinions about the support provided. Feedback from people was positive, for example; 'they (staff) are all right, you get looked after. I don't find anything wrong at all', 'they (staff) give me the help I need, it's a good place to be' and 'they (staff) are always welcoming. They always keep me up to date about (my relative). They are very good here, very kind. We have no worries at all and I can talk to any of the staff if we had'.
When speaking with staff it was clear they genuinely cared for the people they supported and had a detailed knowledge of the person's interests, personality and support needs.
People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.
People's preferences and interests had been recorded and care and support had been provided in accordance with people's wishes.
Is the service responsive?
People regularly completed a range of activities in and outside the service. The home had access to an adapted minibus, which helped to keep people involved with their local community.
Some people required specialised diets for health or personal reasons. We found the service provided food and drinks specifically requested by people. People told us, 'the food is good. We always get a choice. Meals aren't rushed so you can enjoy it' and 'they keep us well fed. I've no grumbles at all'.
People spoken with said they had never had to make a complaint but knew how to make a complaint if they were unhappy. We found appropriate procedures were in place to respond to and record any complaints received. People could be assured that systems were in place to investigate complaints and take action as necessary.
Is the service well-led?
The service worked well with other agencies and services to make sure people received their care in a joined up way.
The service had a quality assurance system, records seen by us showed identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.
Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure people received a good quality service at all times.
Relatives spoken with said that they were happy with the care their loved one received. One relative commented, 'It is brilliant here. The staff know [my relative] well and always take time to say hello and have a chat. I would recommend this home without hesitation.'
We found that before people received any care or treatment they were asked for their consent and the staff acted in accordance with their wishes.
We found that people's care and welfare needs were assessed and each person had a written plan of care that set out their identified needs and the actions required of staff to meet these.
We found that medicines were being obtained, recorded, handled, dispensed and disposed of in a safe way.
We saw that a satisfactory recruitment and selection procedure was in place to ensure that staff were appropriately employed.
We found that people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.
People that we were unable to fully communicate with appeared content and we observed positive interactions with staff and people living at the home.
We spoke with four relatives who were visiting the home and they confirmed that they were satisfied with the care provided.
We found that people's care and welfare needs were assessed and each person had a written plan of care that set out their identified needs and the actions required of staff to meet these.
We found that a policy and procedure for safeguarding adults was in place and staff were aware of the procedures to follow to ensure people were protected. All of the relatives spoken with said that their relative was safe at Springwood.
We found that sufficient numbers of trained staff were provided to meet people's needs.
We found that a complaints policy and procedure was in place. People had been provided with information on how to make a complaint. All of the people spoken with said they had no complaints or concerns about the home.