Springfield extra care service was rated Good overall at its first inspection, with Effective rated Requires Improvement due to care plans not fully reflecting key health and cognitive information. The new registered manager was actively driving improvements in recruitment, training, and record-keeping following high staff turnover.
Concerns (8)
moderate
Care planning
: “People's needs had been assessed however care plans did not fully reflect key information relating to people's needs.”
moderateCare planning: “A care plan audit undertaken on 23 March 2022 identified this as a concern but key information had still not been included in the care plan by the audit target date of 31 March 2022.”
moderateStaff competency: “the person was periodically supported by staff who did not know them so well and would not be aware of this key information.”
moderateStaffing levels: “The service had experienced high staff turnover since registering with the Care Quality Commission. This had had an impact on consistency in people's care and support”
minorConsent / capacity: “Care plans did not clearly reflect people's mental capacity had been reviewed where there were changes to their memory or cognitive functioning”
minorStaff training: “Some staff felt they would benefit from more in-depth training in supporting people living with dementia.”
minorRecord keeping: “People's care plans did not reflect they had been iinvolved and consulted in reviews of their care.”
minorPerson-centred care: “Other relatives felt their family member would benefit from a food monitoring system to provide assurances the person had eaten sufficient amounts”
Strengths
· People were supported to take their medicines safely with regular audits by the registered manager
· Staff were kind, compassionate and respectful, treating people with dignity and supporting independence
· Robust safeguarding procedures and staff training, with referrals made to other agencies where needed
· Effective infection prevention and control practices including PPE and COVID-19 testing
· Open, person-centred culture under new registered manager driving continuous improvements
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies; supporting people to live healthier lives, access healthcare servicesNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversity; privacy, dignity and independenceNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles; continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated