Archived: Springfield Manor Gardens

Updated 10 October 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This comprehensive inspection took place on 14,15 and 21 August 2018. The first and third day of the inspection was unannounced. The inspection was carried out by two adult social care inspectors and an expert-by-experience. The expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert by experience had a background supporting older people.

Prior to the inspection taking place, information from a variety of sources was gathered and analysed. This included speaking with the commissioning groups responsible for commissioning care and the local authority.

We reviewed information held upon our database about the service and reviewed the service’s current registration status. This included notifications submitted by the registered provider relating to incidents, accidents, health and safety and safeguarding concerns which affect the health and wellbeing of people. Notifications are when registered providers send us information about certain changes, events or incidents that occur within the service.

All the information gathered before our inspection went into completing a planning document that guides the inspection. The planning document allows key lines of enquiry to be investigated focusing on any current concerns, areas of risk and good or outstanding practice.

Throughout the inspection process we gathered information from a variety of sources to help us understand the experiences of people who lived in the home. We spoke with ten people who lived at the home and five relatives to seek their views on how the service was managed. We also spoke with people who lived at Springfield Manor Gardens temporarily as they were receiving intermediate care and were resident on a short term basis. We spoke with the registered manager, general manager and three members of the senior management team. We spoke with two unit managers, the discharge co-ordinator, three nurses and five members of staff responsible for providing direct care. We also spoke with the activities co-ordinator, maintenance person and the chef on duty. We activated the call bell three times during our visit to assess staff availability and response times.

As part of the inspection process we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spent time sitting in communal areas watching day to day activities, communication, relationships and care practices taking place. We did this to assess the quality of interactions that took place between people living in the home and the staff who supported them.

To gather further information, we looked at a variety of records. This included care plan files related to six people who lived at the home. We observed the administration of medicines and looked at administration and recording forms related to the management and administration of medicines and topical creams on both units. We viewed a training matrix and the recruitment records of four staff. We also looked at other information which was related to the service. This included health and safety certification, team meeting minutes, policies and procedures, complaint and concerns records and maintenance procedures.

We used all the information gathered to inform our judgements about the fundamental standards of quality and safety at Springfield Manor Gardens.

Updated 10 October 2018

The inspection visit took place on 14,15 and 21 August 2018. The first and third day of the inspection were unannounced. This meant people living at Springfield Manor Gardens, their relatives, the registered manager and staff working there did not know we were visiting.

Springfield Manor Gardens is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Springfield Manor Gardens is registered to accommodate up to 51 people who have nursing needs or people living with dementia. The ‘Bluebell unit’ supports people who require nursing and / or residential support. The ‘Primrose unit’ delivers intermediate care. Intermediate care is for people who are recovering from an illness or stay in hospital but still require some nursing support.

The home comprises of several communal areas, two dining areas and a tea room. All accommodation is located on the first and second floor. The communal areas are accessed by two lifts or stairways. The home has a large garden area with seating for people to use and car parking is available. At the time of the inspection there were 43 people who lived at the home.

The service had a registered manager in place. 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 2008 and associated Regulations about how the service is run.

We had not previously inspected Springfield Manor Gardens. This was their first inspection since they had registered with the Care Quality Commission in December 2017.

At this inspection visit we found breaches were identified to Regulations 10, 11, 12, 17, 18, and 19 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Care plans we looked at did not always have all the appropriate person-centred information in them to promote safe individualised care. People’s preferences and cultural needs were not consistently addressed and met.

Staff we spoke with were aware of the principles should someone require being deprived of their liberty. Whilst good practice guidelines were considered these were not consistently implemented to ensure all principles of the Mental Capacity Act (MCA) 2005, were lawfully respected.

The registered provider failed to ensure the proper and safe management of medicines. People preferences on the administration of medicines and guidelines on when to administer medicines were not consistently followed.

Recruitment processes for ensuring staff were suitably qualified to work with people who may be vulnerable were not always implemented. This was because suitable checks had not been consistently applied in a timely manner.

We found deployment of staffing was not always effective to ensure the safe care of people. Staff were not always suitably allocated to ensure people remained safe.

You can see what action we told the provider to take at the back of the full version of the report.

The registered provider had failed to ensure notifications were submitted to the Care Quality Commission in a timely manner.

We have made a recommendation the provider follows the requirements in the relation to submitting statutory notifications.

There was a complaints procedure which was made available to people and visible within the home. However, we noted one complaint was not investigated in a timely manner.

We have made a recommendation the provider seeks guidance about the management of complaints.

People told us staff were caring and patient. One person said, “If I have to be somewhere, it’s the best place I can be.”

We saw evidence of activity events that had taken place and of scheduled future events.

We found the service did have clear lines of responsibility and accountability. The registered manager was supported by a general manager who shared the responsibility of managing the home. There were also two unit managers and a discharge co-ordinator who took on management responsibilities.

The staff had daily handover meetings to share up to date information on people. They also had formal staff meetings and senior management meetings to share information and plan and review performance. One staff member commented, “We are still at that settling in period with the new company and getting things right. It’s a journey we are still on, but definitely in the right direction.”

The registered provider was in the process of refurbishing the home to ensure people were living in an environment that promoted their safety, independence and positive wellbeing.

Staff had received safeguarding training and understood their responsibilities to report unsafe care or abusive practices.

Staff understood the importance of delivering end of life care that promoted people’s preferred priorities of care.

Staff wore protective clothing such as gloves and aprons when needed. This reduced the risk of cross infection. We found supplies were available for staff to use when required, such as hand gels.

The management team used a variety of methods to engage with people their relatives and staff. Staff told us the management team were approachable and relatives told us the general manager took regular walks around the home to assess the environment.

The service had procedures to monitor the quality of the service provided. There were systems to record safeguarding concerns, accidents and incidents and corrective action took place as required.