The Springs Care Home

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 inspection this key question was rated requires improvement. At this assessment this key question remains at requires improvement. We identified improvements were needed in management oversight and governance. The service had a newly appointed peripatetic manager in post at the time of our site visit. They were committed to improve the safety and quality of care being delivered and the provider had an action plan in place. However, these were not yet embedded. The systems for governance and oversight had not always been effective in identifying the service’s shortfalls. People and families spoke positively about managers.

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.

Most staff we spoke with understood the vision for the organisation and were supportive of the new peripatetic manager. Staff and leaders shared where they feel the service needed to drive improvements. Managers were also supportive of this and told us they would be committed to ensuring improvements were made to enhance people’s quality of life. Managers told us they understood the importance of gathering and listening to people and their relatives views on the service, but this needed further improvement to ensuring they were capturing everyone’s voice. Whilst we saw some of these improvements being made during the assessment, these were not yet fully embedded. Staff spoke positively about the culture in the service.

The provider had not always sought feedback from people and families which had not ensured a fully inclusive approach to developing care plans. Staff had not always had the opportunity to discuss their professional developments through regular supervisions and appraisals. We shared this with managers who had started implementing these actions.

Inspectors spoke with 5 staff members and the management team. Staff feedback was mainly positive, staff were happy to be working at the service and said they would recommend it to others. Staff said managers were approachable and supportive and could speak with them if needed. One staff member said they felt more staffing was needed on 1 unit, to enable people to have some time to do activities and for nurses to complete their administrative roles effectively.

The peripatetic manager had a good understanding of their role and regulatory responsibilities and was engaged with us regarding making improvements at the service. Managers acknowledged previous leadership had not always identified shortfalls at the service. After sharing our findings managers were reflective of our feedback and kept inspectors updated regarding the progress which had made during and after the onsite assessment.

Staff spoken with across all units said they were able to speak up, share views and make suggestions and felt these would be listened to. The peripatetic manager said they felt supported by the senior management team and was able to access support and advice from colleagues when needed. Additional senior support had been provided at the service whilst improvements were being made.

The provider had a whistleblowing policy in place and this had been reviewed in February 2024. The policy gave clear guidance for staff to follow and encouraged staff to raise concerns where needed. Systems to encourage people using the service to be able to communicate and speak up would benefit from further improvement.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The management team had identified some areas as needing improvement and these were in the process of being addressed. Staff told us they understood their roles and responsibilities within the team and had made suggestions on how the service could make improvements. The peripatetic manager was able to provide us with assurances on how these improvement's were going to be made by updating inspectors through improvement processes. The management team were aware of when to notify incidents to the relevant external agencies.

The provider carried out regular audits and checks however these had not always identified risks or improvements. For example, there had been a new door fitted to a kitchen area which posed a toppling risk to people. The provider had not completed a risk assessment to identify if they were able to mitigate the risk. We shared this with the provider who removed the door shortly after our onsite visit. Managers were reflective of our feedback and kept inspectors updated regarding the improvements which had been made during and after the onsite assessment. The provider was in the process of reviewing the service's audits to ensure the information gathered was providing accurate information. There was a strong emphasis to ensure these improvements were made without delay.

Most people and relatives spoke positively about collaborative working with the service and external professionals. Relatives they were kept informed of any changes to their loved ones care. One senior leader from a local partner told us "We have recommended the home to friends". Peoples care plans demonstrated where referrals had been made.

The provider told us they work in partnership with other managers and share knowledge between Bupa services. There was evidence in people's care plans of the service working collaboratively with external professional's and the management team shared updates with people and families. The service held daily meetings where updates and clinical care changes were discussed and actions set for any tasks which required completing.

We received mixed feedback from partners. The provider was working with the local authority to make improvements regarding evidencing clinical oversight and escalation following their quality visit. Professionals visiting the home spoke positively about the service and said people were well referred appropriately, staff were well trained and people were well cared for.

Where referrals had been made to external professionals information had been documented in peoples care plans and guidance was shared with staff. For example, 1 person had been referred for occupational therapy for a review. Additional equipment had been sourced for the person and their care plan had been updated to reflect this. We also saw information for staff to follow in relation to managing people’s diabetes, and what actions would need to be taken should a person become hyperglycaemic.

The management team and staff listened to our concerns from our onsite assessment and provided us with some follow up emails and documentation of assurances. Audits which had been completed prior to our visit, had not always identified the shortfalls we found during our assessment. The senior management team told us they had not reviewed the previous managers inhouse audits thoroughly as they had a " level of trust". The provider recognised these systems were not effective and had amended their audit review process. The peripatetic manager told us the support network within Bupa was supportive and gave examples of how they could access and share information with colleagues. 1 example shared was when they had had issues using the E-MAR system and were able to call upon another registered manager within Bupa services for support. The peripatetic manager was part of a managers group where queries could be raised and they had access to a 24 hour helpline for advice and support within Bupa services.

The providers service improvement plan had identified some shortfalls at the service, for example, inconsistent staff supervisions and people, relatives and representatives involvement in care planning. We reviewed the service's fire risk assessment and identified some recommendations which had been advised from a previous inspection had not been actioned. For example, night staff had not completed fire evacuation training, and there was not sufficient staff allocated to support a bariatric person evacuate in the event of a fire drill. We asked the provider to review their recording of medicine patch rotation as this has also been a shortfall in their previous inspection.