Southdowns Nursing Home

Updated 25 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was undertaken by 1 inspector.

Service and service type

Southdowns Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Southdowns Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR) on 11 October 2022. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We reviewed documentation, inspected the safety of the premises, and carried out observations in communal areas. We spoke and met with 14 people who used the service about their experiences of the care and support they received. We spoke with 15 members of staff including the director, head of quality assurance, and care staff, and three visitors.

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. This was undertaken in the communal areas of Southdowns Nursing Home.

We looked at a range of records. This included the care records for 10 people, medicine records and 5 staff files in relation to recruitment. Policies and procedures, environmental safety and information relating to the governance of the service were also reviewed. We also spoke with 5 relatives over the telephone and 4 healthcare professionals during the inspection process which was completed on the 4 July 2023.

Updated 25 July 2023

About the service

Southdowns Nursing Home provides accommodation, personal and nursing care for up to 50 people living with physical frailty, sensory impairment, dementia, and mental health problems. There were 46 people living at the home at the time of our inspection. Accommodation is arranged over 2 floors and each person had their own bedroom. Access to each floor is gained by a lift, making all areas of the home accessible to people.

People’s experience of using this service and what we found

The governance systems in place did not support the service to consistently improve and sustain safe care delivery. Audit systems and processes failed to identify risks to people's safety. There was a lack of clear and accurate records regarding some people's care and support. For example, people who lived with emotional distress and how staff manage their needs safely.

Communication methods used between staff were not always used effectively to inform staff of changes to people’s care. Care records were missing vital points for staff to follow up on, such as recent incidents, bruising noted or who was not receptive to personal care. Changes to people’s health and well- being were therefore not always planned for and monitored effectively.

Whilst staff numbers were appropriate and based on peoples’ dependency needs, the deployment of staff had the potential to impact on peoples’ safety. For example, lack of supervision in communal areas.

People received care and support from staff who were appropriately recruited and trained to recognise signs of abuse or risk and understood what to do to safely support people. People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible.

Referrals were made appropriately to outside agencies when required. For example, GPs, community nurses and speech and language therapists (SALT). Notifications had been completed to inform CQC and other outside organisations when events occurred.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 31 December 2019).

Why we inspected

We received concerns in relation to staffing, risk management and care delivery. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Southdowns Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to safe care and treatment and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.