Springfield House

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 good governance.

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, risks or needs of people living at the service or the wider community they were part of.

The leadership team were unable to describe any formal strategic aims or a service vision, and there was no documented evidence of such a vision being shared with staff. These areas were not reflected in staff meeting minutes, supervision notes or other governance records. The registered manager told us their key aim was for people to be “happy and healthy,” which reflects caring intentions. However, this had not been developed into a clear direction or shared culture that promoted openness, reflection or challenge. This limited the provider’s ability to identify and respond to risks associated with closed cultures, particularly in a small, isolated setting.

The provider had a statement of purpose, but this document had not been reviewed and did not set out clear information about the services provided, the regulated activities delivered, or the needs of the people the service is designed to support. As a result, it did not support transparency or provide a clear framework for staff, people using the service or external stakeholders to understand the provider’s values, expectations or safeguards.

There was no evidence that leaders involved staff, people using the service or relatives in shaping the service’s future direction. Staff meeting minutes did not show discussions about aims, improvements, or the values underpinning the care provided. This meant opportunities to challenge practice, learn from feedback, or identify emerging risks, including closed‑culture indicators, could be missed.

However, people experienced a warm and caring atmosphere in the home. Staff interactions were positive, respectful and person‑focused. While this reduced the risk of immediate poor practice, it did not replace the need for clear leadership, shared values and active oversight to prevent the development of closed cultures.

Leaders did not always demonstrate the full skills, knowledge or systems required to lead the service effectively.

The registered manager had been in post for more than five years and had completed a Level 5 qualification in Leadership and Management. However, the provider did not have embedded oversight systems or assurance that regulatory requirements were being consistently met. Gaps we identified, including governance arrangements, quality assurance, and oversight of people’s rights and choices, indicated that leaders had not fully grasped how regulatory expectations should be embedded into everyday practice. There was limited evidence of reflection on learning needs or actions taken to address leadership or compliance gaps.

The registered manager was visible within the service and heavily involved in the day‑to‑day running of the home. They undertook the majority of hands‑on care tasks, which helped them maintain a close understanding of people’s routines and immediate wellbeing. However, this operational focus meant they had limited capacity to step back and fulfil their leadership role effectively, including maintaining robust governance, reviewing compliance, and driving continuous improvement.

However, the registered manager was well known to people living at the service and was described by staff as approachable and supportive. Their presence contributed to a calm and caring environment, and staff felt able to speak with them openly.

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

Staff told us they felt confident to raise concerns or challenge poor practice, and they were aware of the term “Freedom to Speak Up” and what it meant in relation to their role. One staff member said, “Yes, I have the freedom to speak up, and I wouldn't have to worry about repercussions.”

Staff described an open and supportive culture in the home, where they could approach the registered manager with any issues. They told us they felt listened to.

The provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The staff team was made up of family members and bank staff who worked occasionally. All staff spoke positively about their experiences at work and told us they were treated fairly. The provider was aware of their responsibilities in relation to the Equality Act 2010. Training in equality and diversity was part of mandatory staff training, and the provider had the relevant policy in place.

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.

The provider was working closely with the local authority and had made noticeable improvements in governance processes in recent months. However, the concerns we identified during this assessment, including issues related to safety, practice not being reflective of policies, required records not being kept related to how care and support were delivered, and ensuring consent was lawful, had not been identified through the provider’s own governance procedures. This demonstrated that existing checks were not sufficiently robust to identify and address key risks, or to assure that people’s rights, choices and outcomes were being consistently promoted in line with Right support, right care, right culture principles.

When we highlighted these gaps, the provider responded quickly and began taking action to resolve them. However, further work is required to strengthen the overall governance structure. Key governance processes had either not been completed for several years or had only recently been restarted. This meant the provider could not yet evidence sustained improvement.

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 service had partnerships with social and health care professionals such as the local authority, advocacy services and district nursing teams and was working with a local nursing home to collaborate on things like staff supervision and governance processes.

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.

There had not been any complaints or safeguarding concerns recorded for several years. Although there were recording systems in place for these events, there were no processes in place to review or analyse trends.

Staff meeting minutes did not show evidence of reflective discussions, problem solving or service development, and the registered manager was not part of any external learning forums or networks related to supporting people with a learning disability and autistic people that could support ongoing improvement. As a result, we did not always see evidence of opportunities to learn from others or embed best practice.

The provider had been collaborating with commissioning bodies to raise the standard of care and strengthen the quality of documentation. Despite this, additional work was still needed to evidence sustained improvement.