Southway

Updated 1 September 2022

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 two inspectors 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

Southway is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. Southway is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. The inspection activity started on 22 June 2022 and ended on 4 July 2022. We visited the service on 22 June 2022.

What we did before the inspection

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 the information gathered as part of monitoring activity that took place on 11 May 2022 to help plan the inspection and inform our judgements. We also reviewed the information we held about the service. We used all this information to plan our inspection.

During the inspection

We spent time in the home to understand people’s experience of living at the home. We spoke with five people who lived at the home and spoke with nine people’s relatives by telephone. We also spoke with ten members of staff as well as the deputy manager and registered manager.

We reviewed a series of documents and sought clarification from staff to validate the evidence found. We looked at seven people’s care records and checked the medicines for six people. We reviewed three staff employment checks, and various safety plans and checks completed in relation to equipment used, COVID19, and the building, which included fire related equipment. We also reviewed audits completed by the management team.

Updated 1 September 2022

About the service

Southway is a residential care home providing personal care for up to 42 people. The service provides support to older people most of whom were living with different types of dementia. At the time of our inspection there were 40 people using the service.

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

We found there were shortfalls with how the managers and provider responded to accidents and injuries. Investigations were not thorough with safeguarding referrals made to promote people’s safety. Actions were not considered and taken to try and reduce the risk of the injury happening again. Risk assessments lacked details and staff did not always have clear plans to follow. There was also a lack of care planning around some people’s medicines to ensure staff had all the relevant information at hand to guide their actions.

There were shortfalls with plans and drills related to fire safety. We were not confident at times there was enough staff or staff had the right support to spend time with people, talking with them and responding to them when they needed support. Parts of the home and people’s rooms needed decorating, but there was no plan in place to do this.

The registered manager and provider were not carrying regular audits and checks on the quality of the care people experienced. Audits were not effective or not taking place to see what was happening in key areas and consider if changes needed to happen.

People were not always supported to have maximum choice and control of their lives. Staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

People felt happy living at the home. One person said, “No washing up, no ironing, a life of comfort. No one has upset me so far.” Another person said, “Staff are nice here, its ok.”

People’s relatives were confident their loved ones were safe, and staff had got to know them. Relatives spoke of being made to feel welcomed by staff.

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 1 February 2020). At this inspection we found the service had deteriorated.

Why we inspected

We undertook this inspection as part of a random selection of services which have had a recent Direct Monitoring Approach (DMA) assessment where no further action was needed to seek assurance about this decision and to identify learning about the DMA process.

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.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to promoting people’s safety and the managers quality checks on the service 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.