Springfield Nursing Home

At this assessment we identified the provider was in breach of legal regulations relating to safe care and treatment and good governance.

People’s care plans were not always sufficiently detailed to ensure staff had all the information they required to safely meet their needs, and some contained contradictory information. This meant people were at risk of not receiving the care they required to keep them safe.

People did not consistently receive safe care and treatment, risks were not always identified, assessed or managed in a timely or effective way. Staff did not always respond promptly to people’s immediate needs or escalate concerns appropriately. This placed people at significant risk of harm. Staffing levels and deployment of staff around the home did not ensure people’s safety and people and relatives reported delays in responses to call bells. While this had been identified by the management team prior to our assessment and some action had been taken to address this, significant delays in call bell responses remained, placing people at continued risk of significant harm.

The providers systems and processes failed to identify all issues and concerns found at this assessment and systems and auditing processes failed to ensure good governance. The provider’s governance systems had not identified all the concerns we found in relation to risk management, staffing, contradictory and incomplete information in care plans, staffing knowledge and continual learning from incidents.

The management team were responsive to our concerns and conducted internal investigations of the issues we raised, they completed, reviewed and updated assessments of people’s needs, including, care records and risks assessments, implemented new systems and reviewed staff skills and abilities, taking additional action where required. However, any actions and changes made required time to embed to allow continued and sustained improvements. The management team demonstrated they were committed to making the necessary improvements.

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