Springbank 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 remained Good. 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 68 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The management team had a clear vision of the future and direction of the service which put people at the centre of any development, changes and improvements. The service had not had a registered manager since January 2024. A permanent manager had been recently recruited and would be in post in February 2026. In the meantime, interim managers had been recruited. The provider acknowledged that this was not ideal for people or for staff but wanted to make sure the registered manager was the right person, as there had been some poor fits in the past.

Staff spoke to us about the vision and culture of the service. The provider was emphatic about ensuring that people received support based on equality and human rights, and diversity and inclusion. However, staff needed support in understanding some peoples’ behaviours in order to have a better understanding of their role in promoting person centred care and identifying triggers. Some staff said further training in managing situations that may cause distress to other people and staff would be beneficial.

Most staff said that the management team were approachable, listened, and that they feel well supported. Some staff found having different managers overseeing the service confusing, but were looking forward to the newly appointed manager starting. One new member of staff told us they feel welcomed to the home and were on their induction and getting to know the people who lived there. Staff told us that it had been a troubled few months with whistleblowers, staff leaving and change of management, but felt that a new deputy and manager starting would really benefit the home. The staff we met knew people well and were loyal and hardworking.

Staff supported people’s (and staffs’) cultural and spiritual needs. People were treated equally, and their individual needs were met in line with their preferences. The management team were knowledgeable and worked alongside staff to support and promote good practice.
Feedback from staff was in the main positive when we spoke with them. The service aimed to give people consistently good care and staff worked together to try and achieve this. Staff meetings were used by the provider to remind staff about their organisations underlying core values and principles and of any changes coming, concerns and compliments.

Leaders had the skills, knowledge, experience and credibility to lead effectively.We found that the management team was committed to improvement and was open and transparent regarding the improvements in progress and those that were to be implemented. We were told that the focus of the service was to ensure people were safe and supported by skilled staff. There were systems and processes in place to support staff development and progression within their roles. They talked of how they were supported to attend training, gain qualifications and extend their role, for example becoming a medicine giver. Staff supervisions, and staff competencies were a priority of the interim manager as this would give them the opportunity to know staff and their skills.

Staff had not always felt they could speak up and that their voice would be heard. They said this was due to a high staff turnover including managers and deputy managers. CQC had received a high number of anonymous whistleblowing concerns. However, staff also told us that things had improved. One staff member said, “We are now being given opportunities to talk to senior staff, I have brought up concerns in the past and didn’t feel they were taken seriously, too many changes of senior staff, communication was lost for a while, but things are getting better, we have a deputy started and a new manager starting in the New Year.”

We were told that that there were formal and recorded opportunities for staff to speak up which included staff surveys, and team meetings. We saw evidence of staff meetings but these had not been consistent or regular despite changes in the management team.

Staff were aware of the whistle blowing policy and felt that they could raise concerns with the local authority and CQC and be listened to. The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance.

People and their relatives had opportunities to feedback their views about the service and quality of the care they received. People and relatives described the staff and management of the service as having had changes to staff but felt staff were approachable. Complaints were taken seriously and learning from them taken forward. Learning was, where appropriate, also shared across the providers other services. The management team encouraged staff to speak up about positive ideas.

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.

The provider had procedures in place to promote staff well-being and worked to provide flexible working conditions if required. However staff had left for reasons known to the provider regarding zero hour contracts and this was currently being reviewed by the organisation.

The management team we met during the inspection told us they encouraged and supported open communication and there was an open-door policy. The home was proud to be inclusive and supported both staff and people that used the service. The staff team was multicultural, and everyone was respectful of each other.There were robust measures in place to monitor, maintain and promote good mental well-being across the staff group. There was a formal recruitment process and equality, diversity and inclusion policy in place to guide equitable and fair recruitment and selection procedures. Staff were encouraged to undertake training in equality and diversity.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance.

Quality assurance systems were in place, however these had not always been used effectively to consistently improve and monitor the service. The management team were due to introduce a new system in the new year which will improve the oversight and effective governance at the service and this was planned for the New Year (2026). For example, improving care plans and risk assessments, daily log documenting, and introducing a more focused approach for people to reach their full potential.

Staff told us about their duties and responsibilities; they told us how they managed risk and reported concerns to management. However, we found 7 medication error forms, where it was documented that the manager had been informed, but there was no further action recorded. The forms were not completed and therefore no lessons learnt, which had resulted in 6 more errors. We saw on crisis monitoring documents that one person had expressed intention to harm themselves, but appropriate/sensible preventative measures were not taken which had resulted in an incident occurring. This was discussed in full and steps taken to ensure their safety. The Area Manager sent new improved forms during the assessment process, which included a tracker and root core analysis. We were told the implementation of these documents in 2026 were intended to support more robust learning, clearer assurance, and stronger oversight across services, and ensure that learning would be consistently identified, recorded and shared.

Managers and staff understood their roles, and were clear about quality performance, risks and regulatory requirements. Action was immediately taken on areas discussed. We have received actions plans which have been updated during the assessment process.

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.

People were consistently supported across a range of different services and agencies. There were established systems in place to liaise with other professionals. One professional said, “Overall the communication is ok, but the change of senior staff has impacted I think on the communication at times.” The provider told us they were in the process of changing their systems to improve .In addition, within the organisation there were regular meetings and training opportunities that staff and leaders attended. These were opportunities to share knowledge and learning and consider future developments.

They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Whilst there was a lot of information in care plans, there was minimal recorded about the purpose of placement, individual aims and specific outcomes for people. This meant there were minimal positive goals for people to work towards, during their stay.

The provider had used the concerns raised anonymously to keep CQC informed of the leadership within the service and of actions taken.

People and their relatives had opportunities to feedback their views about the service and quality of the care they received. People and relatives described the staff and management of the service as having had changes to staff but felt staff were approachable. Complaints were taken seriously and learning from them taken forward. Learning was, where appropriate, also shared across the providers other services. The management team encouraged staff to speak up about positive ideas.