This inspection took place on 16 July 2018 and was unannounced. A second day of inspection took place on 19 July 2018 which was announced. We last inspected Springfield Park November 2015 and found it was meeting all the regulations we inspected against. We rated it good in all domains. During this inspection we found concerns in relation to some records and governance so have rated it requires improvement.

Springfield Park 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 Park can accommodate 30 people in one adapted building across two floors. At the time of the inspection 20 people were resident, some of whom were living with a dementia.

The service had a registered manager who was on a planned absence at the time of the inspection. We had been notified of this and the deputy manager was managing the home. 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.

This is the first time the service has been rated Requires Improvement. We found a breach of regulation in relation to good governance. Care records for people receiving respite care had either not been written or hadn’t been reviewed since October 2016. There was a failure to follow the providers own policy in relation to respite and short stay admissions. Respite care files had not been audited and the required improvements had not been identified. The deputy manager was responsive to our concerns and immediately took action to develop care plans.

Some care records also lacked detail in relation to the support people needed with regards to the provision of personal care and mobility.

Staff knew people well and we observed care and treatment was provided in a safe and responsive manner. The gaps in care records had not had any direct impact on people’s care. However, the provider is required to maintain accurate, complete and contemporaneous records in respect of each person’s care.

We have made a recommendation that the provider review best practice in relation to fire safety. A fire risk assessment had not been updated to evidence actions had been completed. We found some fire doors were closing at high speed. This was rectified after the inspection. Staff could explain how they would safely evacuate people in the event of a fire.

The environment was in need of an update and the deputy manager was able to offer reassurances that work was in progress to replace carpets and furniture and to improve the décor.

Risk assessments had been completed for all people permanently resident at Springfield Park. Any incidents or accidents were recorded and the information used to review and update risk assessments.

Staff were knowledgeable about how to safeguard people from harm and were confident the registered manager would act to resolve concerns and ensure people’s safety. All concerns were logged and investigated.

Medicines were managed safely and had recently been audited by the pharmacist. Regular medicine audits had been completed and if necessary action had been taken to ensure improvements were made.

People were supported with their nutrition and hydration needs and had access to healthcare professionals such as dieticians, speech and language therapy and GPs and consultants.

There were enough staff to meet people’s needs and recruitment procedures were in place.

Staff told us they had the required training to ensure they could meet people’s needs and that they were well supported by the deputy manager. The team worked well together and supported each other so people received

Springfield Park is a residential care home which provides accommodation for up to 30 older people, who require support and personal care; some of whom have dementia. At the time of the inspection, there were 23 people in receipt of care from the service.

The inspection took place on 18 and 19 November 2015 and was unannounced.

The manager, who had registered with the Care Quality Commission (CQC) in July 2015, was on duty during our inspection, as was a team of care workers and domestic staff. A registered manager is a person who has registered with the CQC 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.

Staff were knowledgeable about safeguarding procedures and there were systems in place for staff to report any concerns to the manager. People told us they felt safe and that they liked the staff who provided their care. Incidents which had taken place were documented and the manager had taken appropriate action in a timely manner.

Risks people faced in their daily lives had been assessed and documented within people’s individual care files. Steps had been taken to ensure actions to mitigate risk were available for staff to follow. These assessments were reviewed monthly and there was evidence that changes to people’s needs were cascaded to staff through team meetings and key worker sessions.

There were enough staff employed at the service to meet the needs of the people who lived there. Staff files showed that the service safely recruited suitable people into their roles. Staff had a mix of skills, knowledge and experience to meet individual needs. The manager ensured that competency checks were carried out regularly and staff told us they were encouraged to develop professionally.

Medication were managed safely and securely stored. A senior care worker was responsible for administering medication and thorough records were kept to document this. One person said, “They are always there when you need them, they give me my medicine when I need it. I think they are wonderful”. The service had recently introduced daily auditing of Medicine Administration Records (MARs) to ensure any anomalies were highlighted and dealt with immediately. Staff displayed knowledge and competency regarding the management of medicines, including the administration of medicines covertly, for people assessed under the Mental Capacity Act 2005 (MCA) as requiring this level of support. Best interest decisions had been documented in each MARs to document the necessary action required by staff.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. The Manager told us there were several people living in the service who were subject to a DoLS. Records showed these decisions had been made in the person’s best interests and had involved other healthcare professionals.

Communal areas of home was clean and pleasant. The service employed domestic staff for cleaning and maintaining the home. We observed staff followed national patient safety guidance and used colour coding equipment to clean in different specified areas of the home. The bedrooms we were invited to observe were also clean and tidy.

Meals were well-balanced and nutritious. The menu was varied and people were given a choice of food options if they did not like the meal prepared. Snacks and hot drinks were served twice a day and cold drinks were available at all times in the lounge areas. We observed staff encouraged people to drink and offered people cups of tea throughout the day in addition to the set times. Staff listened to people’s preferences and offered them choices.

Staff were recruited safely, well trained and supported in their role through regular supervision, appraisal and staff meetings.

It was evident that the staff cared about the people who lived at the service. They treated people with kindness and compassion and staff were able to tell us about people’s life histories and individual preferences. We observed lots of positive interactions between staff and people throughout a variety of different activities. Staff were continually promoting socialisation and they encouraged people to interact with each other as well as the activity. On the upper floor, the décor had been improved to provide stimulation to people with dementia care needs. Doors were painted different colours and had laminated photographs fixed to them to help people identify their own room. The manager had recently introduced memory boxes which were on display outside each bedroom.

Care plans were in place for each person and they contained detailed information about the individual. There was evidence that the staff were working in partnership with external healthcare professionals and other agencies to achieve the best outcome for people. Care files contained hospital passports and the Alzheimer’s Society “This is me” document, so that personal information would travel with people if they needed to leave the service. Care plans were reviewed monthly by keyworkers and changes were shared with the staff team through team meetings.

The manager kept robust records, such as those related to complaints, accidents and incidents. These records showed investigations had taken place and where necessary action plans were drafted to manage the situation and prevent repeat events. The manager also had a record of relevant people she had informed including the local authority and CQC.

The manager was proactive with quality monitoring. There were a number of audits in place to monitor that the service was providing safe, quality care. Where issues had arisen, action plans were in place to address these.