Southwoods Nursing Home

Updated 10 August 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

Two inspectors and an Expert by Experience undertook the inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Southwoods 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. Southwoods 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 a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity started on 15 June 2023 and ended on 21 June 2023. We visited the service on 15 and 21 June 2023.

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). 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 of this information to plan our inspection.

During the inspection

We reviewed 3 people’s care records and a number of records relating to medicines administration. We spoke with 1 person who lived at the service and 6 relatives. We spoke with the nominated individual, the registered manager, 5 staff, a cook and a domestic. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Updated 10 August 2023

About the service

Southwoods Nursing Home provides accommodation and nursing care to up to 38 people in one adapted building. At the time of our inspection there were 28 people using the service, including a person with a learning disability.

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

Medicines were not always administered safely. Medicine records were not always completed correctly.

There was an organised governance framework in place, which monitored all aspects of care and support and the running of the home. This had been developed over the last eight months by the new management structure and was continually reviewed. However, it had not identified the concerns we found regarding medicines administration.

We have made a recommendation about the governance of medicines administration.

Systems, processes and practices safeguard people from abuse. Risks to people were assessed and their safety monitored and managed to keep people safe, and support their independence. Sufficient numbers of suitable staff were deployed to support people to stay safe and meet their needs. People were protected by the prevention and control of infection, however advice from the recent IPC audit in respect of the environment had not yet been implemented. Lessons were learnt and improvements made when things go wrong.

People's needs and choices were regularly assessed and care. Treatment and support were delivered as required, and within best practice guidance. Staff received induction, training and regular support. People were supported to eat and drink and maintain a balanced diet. Staff were well-informed about people's nutrition and dietary needs. Robust monitoring was in place. Staff teams and services worked together and were supported by detailed handover records and documentation. People were supported to access to healthcare services. Regular visits from health professionals took place. The home had commenced a programme of refurbishment, which meant people lived in an environment suited to their needs. The home had a maintenance plan for further refurbishment works; this included recent recommendations from the fire service. Dementia-friendly signage was in place for toilets and bathrooms.

Consent to care and treatment was sought in line with legislation and guidance. MCA assessments and best interest decisions were used appropriately, as were DoLS applications.

There was a clear vision and strategy for the home. The minutes from meetings with staff, people and relatives and our observation showed there was a positive, open and person-centred culture at the service.

People, relatives and staff were all actively and regularly engaged in the running of the home. Links with the local community were in place, for example, with local schools and there were plans to expand this community involvement. The new management structure was constantly reviewing and learning from all practices and areas across the home. There was a culture of learning and improving. The service had worked closely with local authority colleagues and other professionals to learn and improve.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 27 May 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made to the oversight, monitoring and auditing to ensure people's needs were being met and records were accurate and consistent. However, at this inspection the provider was in breach of a different regulation.

The service remains rated requires improvement. This service has been rated requires improvement for the last five consecutive inspections.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 14 and 19 April 2022. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve their governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has not changed. This is based on the findings at this inspection.

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

Enforcement and Recommendations

We have identified a breach in relation to medicines at this inspection.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.