Springfield House

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.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not consistently demonstrate a learning culture where openness, reflection, and learning were used to improve safety and quality. Although systems were in place and staff knew how to report concerns, there was limited evidence that learning from incidents, feedback, or identified risks was actively reviewed or used to make improvements. Risks associated with closed cultures had not been identified.
There were systems in place to support the provider to report incidents and safety events, but it had not been possible to review these because there had only been one incident, a minor accident, recorded since we last inspected.
However, the provider’s recent collaboration with the local authority quality team evidenced a significant amount of progress in response to feedback and an action plan. Not all issues identified at inspection were in this action plan.
When staff were asked about the process for reporting incidents and accidents, one staff member told us, “'I’d make sure it was escalated to [registered manager], and I'd fill out an incident report.”
The service is operated from a remote location, and the staff team is predominantly made up of members of the same family. These factors can increase the risk of closed cultures developing if risks are not identified and managed. We did not see evidence that the provider had recognised these risks or taken steps to reduce them, such as regularly reviewing how the service operates, assessing the risks, seeking outside views, or encouraging learning and reflection. This meant there was limited assurance that potential warning signs of a closed culture would be identified and addressed early.
 

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.

One health professional told us, “[Staff] are very proactive and they refer to us quickly if anybody needs our input.” We were assured transitions had been managed safely because we saw detailed records about hospital admissions.

Systems were in place to support people to transition from the home to the hospital. People had hospital passports which included details about how best to communicate with the person, important contacts, medicines and their physical health and emotional wellbeing needs. We found these wouldbenefitfrom being reviewed and updated.

One staff member told us about what happens when people are admitted to hospital, “We take MAR charts, hospital passports and their care plan. [Staff] always stay with people when they are in hospital.”

The provider did not always work effectively with people and health professionals to fully understand what being safe meant to each person and how best to support this. While staff aimed to improve people’s lives, safeguarding arrangements were not always applied consistently. This meant there was not always sufficient assurance that people were fully protected from the risk of abuse, avoidable harm, or neglect.

The provider had a safeguarding policy that explained how to report concerns to the local authority and to CQC. However, the safeguarding log had not been kept up to date. The provider told us there had been one safeguarding concern, but the local safeguarding team decided it did not meet the threshold for an investigation. The provider accepted that this concern should have been recorded in their safeguarding log and assured us future safeguarding concerns would be reported appropriately.

Staff had completed safeguarding training. They understood what types of situations a safeguarding concern might be and how to report them. Staff we spoke with were clear they would know how to report any worries they had. One staff member told us, “If people appear unhappy, their behaviour changes or if they had bruising, I'd contact [Registered Manager]. If I needed to, I'd contact the local authority safeguarding or CQC.”

People can only be deprived of their liberty to receive care and treatment when the correct legal processes are followed. We checked whether the service was working in line with the Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLS). Where people needed DoLS authorisations, the provider had applied to the appropriate authority.

The provider did not always work well with people to understand and manage risks.

We found some gaps in care records and risk assessments. One person had bedrails fitted in a way that did not match their existing risk assessment, which had not been reviewed for several years. We raised this with the provider, who took immediate action.

Another person had asthma and a clear care plan, but there was no risk assessment to guide staff on how to support them safely. We also identified a person with a known food allergy, but there was no risk assessment or guidance for staff on what symptoms the person may present with or what to do if the person came into contact with the allergen. During the inspection, the registered manager put clear guidance in place.

The provider had recently updated its risk management policies, and there was a system in place to review and update them. Some individual risk assessments were in place, such as guidance to support a person with diabetes to safely self-administer their insulin. There was also up to date guidance for staff on responding to specific medical emergencies, including epileptic seizures. One relative told us, “I think [person using the service] is very safe...I don't have any concerns.”

The risks associated with support during the night had not been assessed for each person and people had not been consulted. This put people at risk of receiving standardised support that was insufficient or overly intrusive.

The provider did not always detect and control potential risks in the care environment. They did not always make sure that equipment, facilities and systems supported the delivery of safe care.

During the inspection, we found several environmental safety issues. Not all radiators had been risk assessed and did not have covers, increasing the risk of burns or injury. The laundry room, which contained cleaning products stored on open shelves, was not secured, and risks were not assessed, meaning people could potentially access harmful substances. Whilst the provider told us mixer valves were in place to limit the temperature of hot water, routine water temperature checks for sinks in bedrooms and bathrooms had not been completed to reduce the risk of scalding. Risks associated with windows had not been assessed.

There was a legionella risk assessment for the property; however, water temperatures had not been monitored, which meant the provider could not be sure systems remained safe. The home did not have a valid electrical safety certificate on the day of inspection; however, this was promptly rectified by the provider. Portable electrical equipment had been recently tested.

Fire safety equipment had been regularly checked, but no fire drills had taken place. The fire risk assessment was nine years old and therefore significantly out of date. We found several fire doors that either did not close properly or had no closing mechanism at all. There was no fire action plan displayed for people or staff to follow. The written fire procedure we reviewed instructed people to activate the fire alarm, but there was no alarm system in place. Smoke detectors were fitted in parts of the home, but not all bedrooms had them. The registered manager had been in contact with the fire service prior to our visit, however we found the risks associated with fire did not meet the standards of a regulated care home. We have contacted the fire service for their advice and input.

The home was clean and tidy throughout, including people’s bedrooms. Some plastering work was underway in one room, and the provider assured us this would be finished and decorated promptly. The provider did have systems in place to monitor environmental safety, but these had not always been used effectively.

The provider assured us they would address these shortfalls and provided some evidence of actions taken. We have not assessed the effectiveness or sustainability of the changes they have made.

The provider could not always evidence there were enough qualified, skilled and experienced staff.

We found concerns with staff recruitment and deployment. Each staff member had a recruitment file, however these did not all contain all the required recruitment check documentation. This meant the provider could not demonstrate that all staff had been recruited safely.

The registered manager worked long hours, and the risks associated with this on the quality of care and their own wellbeing had not been assessed.

The provider told us they maintained staffing levels based on assessed needs, but we were unable to verify this because staff rotas and a dependency tool were not available. One staff member, who worked during the day told us they checked on people every 2 to 3 hours during the night. These checks were not recorded.

For 1 person who was assessed as needing 2 staff members to support them with all transfers, personal care and dressing, the provider could not evidence 2 staff were always present. We spoke to the registered manager about this and could not be assured this person was supported by 2 staff for all transfers. Staff were receiving supervision, and records showed this included discussion about their professional development. However, supervisions were not being carried out in line with internal policy which stated staff should receive six supervisions per year.

One staff member told us, “Supervisions are helpful. They point out where I could improve and what I'm good at. They help me reflect on my personal development.” However, members of the leadership team were supervising and being supervised by family members. This arrangement limited impartiality and oversight. The registered manager recognised this during the inspection and was seeking external support from a local provider to ensure supervision was carried out independently.

Staff were knowledgeable, skilled and experienced. They spoke positively about the people they supported and were clearly committed to their roles. Staff had completed mandatory training and the Care Certificate.

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. One health professional told us, “I have no concerns with IPC.”

The provider had an infection prevention and control (IPC) policy, and staff had undertaken IPC training. The environment was clean, and separate handwashing sinks were available. One relative told us, “I'm there at least every 3 weeks, I sit in there for 30 minutes and the kitchen is always spotless.”

Personal protective equipment was available for staff to use when needed.

The provider did not always make sure that medicines and treatments were safe or managed in a way that met people’s needs, capacities and preferences.

We found some medicines had been pre-dispensed ahead of time, including enteric coated tablets. This was not safe practice. We raised this with the provider, who acted quickly and sought advice from a pharmacist. The pharmacist confirmed these medicines should not be pre-dispensed, and the provider took immediate steps to change their practice.

However, medicine stocks were accurate and there was no sign of excess supplies. People were having regular medicine reviews, and for one person there was clear evidence of reducing medicines where appropriate. We did not find any signs of over‑medicating.

Staff who administered medicines had completed training and competency assessments. Clear PRN (when required) protocols were in place for medicines such as buccal midazolam and insulin, so staff knew exactly when and how to give them. One relative told us, “[Registered manager] always lets me know immediately if there's any medical issues or medication changes.”