Archived: Southfield Court Care Home

Updated 17 May 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

The inspection was carried out by 1 inspector, 1 specialist advisor and an Expert by Experience. 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

Southfield Court Care 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. Southfield Court Care 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. However, the registered manager was not present during the inspection, and an interim manager had been assigned to oversee the service.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed all the information we had received about the service since its last inspection in 2022. We requested feedback from stakeholders, including local safeguarding, infection control and commissioning teams. 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 this information to plan our inspection.

During the inspection

We spoke with 9 people who used the service and 4 relatives about their experience of care provided. We gathered feedback from 7 staff members including the interim manager, the regional manager, the clinical lead, and care staff. We looked around the building and observed people being supported.

We reviewed a range of records including 8 people’s care plans and risk assessments. We reviewed a variety of medicines records. We looked at 4 staff files in relation to recruitment and a sample of agency staff recruitment profiles. We reviewed records relating to the management of the service, including health and safety records and audits.

We had a meeting with the interim manager and the regional manager during the inspection to discuss queries in relation to safe care, good governance, and staffing. We requested additional evidence, including training and incident records and policies following the site visit.

Updated 17 May 2023

About the service

Southfield Court Care Home is a nursing home providing accommodation for up to 50 people, who require personal care. The service provides support to people who have physical health needs and conditions such as dementia. At the time of our inspection there were 34 people using the service.

The home is set out across 2 floors, each with a communal lounge and dining area.

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

We found people were at risk of harm as medicines and risks associated with people’s care were not always safely managed. Risks to people and incidents were not always identified, communicated with other staff, or reviewed to ensure safe and effective care.

Staff were not always appropriately trained to meet the needs of people and feedback about how staff were support varied. Feedback from staff suggested staffing levels were not always in line with people’s needs. We found the service was not using its governance processes effectively to review staffing levels or people’s support needs. We found evidence of good partnership working with other health and social care professionals.

The premises was generally clean. However, we found it was not suitable for the needs of people using the service, particularly people diagnosed with dementia and had strong odours throughout.

People and their relatives told us they felt the care provided was safe. Staff were trained in safeguarding and some staff could give examples of different types of abuse. People and relatives mostly spoke positively about the care provided by staff, and we saw some positive interactions between staff and people. Recruitment was managed safely, although records associated with recruitment needed reviewing to ensure the most up to date information was available.

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. However, we found conditions relating to people’s Deprivation of Liberty Safeguards (DoLS) were not always actioned in a timely manner.

There was an interim manager at the service as the registered manager was not present. The interim manager was working to address shortfalls in practice and improve governance oversight. The interim manager and regional manager were responsive to our inspection findings, and we received updates about what actions they were taking to address concerns.

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 06 October 2022). At our last inspection we recommended the provider reviewed medicines records and took action to update their practice. At this inspection the provider had not addressed this. We also made further recommendations in the responsive domain; this domain was not looked at as part of this inspection.

Why we inspected

The inspection was prompted in part due to concerns received about poor recording, staffing levels, incident management, management oversight, training and nutrition and hydration. A decision was made for us to inspect and examine those risks.

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.

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 changed from good to requires improvement based on the findings of this inspection. 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 Southfield Court Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care, medicines, staff training and support, person-centred care, and good governance. Please see the action we have told the provider to take at the end of this report.

We have made a recommendation about infection, prevention, and control practices.

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.