Archived: Southlands Court Residential Home

Updated 13 November 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This unannounced inspection took place on 5 October 2015. It took place to check whether there were effective systems to assess, monitor and mitigate risks to people using the service. This was because our inspection in June 2015 found people were not protected through risk management at Southlands Court. The inspection team consisted of one inspector.

During our inspection we received information from three people who used the service and one person’s family. We reviewed the records of the last person admitted, and the last staff member recruited, to the service. We spoke to three staff members, the registered manager and registered provider. We looked at quality monitoring records, such as quality monitoring audits, servicing records and survey results. We received information from a learning advisor visiting the home to work with a staff member undertaking an apprenticeship in care work.

Updated 13 November 2015

We carried out an unannounced focused inspection on 5 October 2015.

We last inspected the home in June 2015 and found breaches in six of the regulations we looked at. Following that inspection, the provider sent us an action plan. We did not feel it was sufficiently comprehensive and so requested a second action plan, which was more comprehensive. The June 2015 inspection found there were not effective systems to assess, monitor and mitigate risks and records were not always accurate and complete. We gave the provider until 30 September 2015 to ensure those systems were in place so that people’s health and safety were better promoted. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met that one legal requirement, as this related to the way the home was run. The other breaches will be looked at during a subsequent inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk

Southlands Court provides accommodation and personal care for up to 25 people. Any nursing needs are met through community nursing services. There were 24 people resident at the time of the inspection.

The service has a registered manager. 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.

The arrangements for staff training were used more effectively. Staff were receiving the training which the registered manager said was required for them to provide safe care, such as moving people safely.

Staff induction was structured and was now started prior to new staff delivering care to people. A structured supervision of their work was planned to ensure new staff’s practice would be monitored and they would be supported. This structured supervision was then to be rolled out to include all staff members; this had not yet started. People told us, ”On the whole staff know what to do” and “Very good really.”

Risks were being assessed and managed. Staff meetings informed staff of where improvement was needed, such as not propping open fire doors and medicine management. The registered manager was undertaking regular audits, such as the safety of the home environment. Maintenance arrangements were improved and now included work being signed off so it was clear what had been dealt with and what still needed work. On admission risks to people’s health and welfare and a plan of how to deliver their care were in place for staff reference. Policies and procedures had been reviewed in July 2015 as a source of staff reference, although the registered manager expressed the opinion they were of no value.

People using the service, their families and health professionals had their opinion of the service surveyed. Where possible the registered manager had made changes in response to their comments. However, recruitment difficulties were negatively affecting what could be achieved, such as more outings. The registered manager was well known to people and their families and available to hear their views and support staff. She was supported by the provider who visits the home most days.