Background to this inspection
Updated
11 February 2022
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.
As part of CQC’s response to the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. This was a targeted inspection looking at the infection prevention and control measures the provider had in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.
This inspection took place on 20 January 2022 and was announced. We gave the service 24 hours’ notice of the inspection.
Updated
11 February 2022
Southmoor Lodge is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Southmoor Lodge provides personal care in one adapted building for up to 40 older people, including some who may be living with dementia.
At our last inspection in January 2017 we rated the service as Requires Improvement. People who used the service were not fully protected from harm or abuse or risks associated with unsafe or ineffective care. The provider did not have effective arrangements for service monitoring, evaluation and improvement when required. These were breaches of Regulations 11, 12, 13 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve the service. This was because the provider needed to improve the key question about how they ensure the service is safe, effective and well led. This was the first time the service was rated as Requires Improvement. At this inspection we found the provider had made improvements to meet the relevant requirements.
We carried out this inspection on 12 March 2018. The inspection was unannounced. There were 23 people living at the service. We rated the service as Good.
There was a registered manager at the time of our inspection. 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People felt safe and they received safe care at the service. People were protected from the risk of harm or abuse by sufficient staff who were safely recruited.
Staff understood people’s safety needs associated with their care, environment and any medicines they needed to take, which were detailed in their written care plans for staff to follow. Staff supported people safely and consistently when they provided their care and in the least restrictive way. This helped to reduce any known risks to people’s safety.
The environment and care equipment was clean, well maintained and free from observable hazards to people’s safety. Staff were provided with relevant equipment, guidance and training, which they used and followed to help ensure this. Emergency contingency plans were in place for staff to follow for likely foreseen emergencies to ensure people’s safety, which they understood.
People received effective care from staff who were trained and supported to ensure this.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
Staff understood people’s health conditions, related care needs and supported people to maintain and improve their health and nutrition. This was done in consultation with relevant external health professionals and staff followed their instructions for people’s care when required.
People were supported in the way they preferred and needed to eat and drink sufficient amounts they enjoyed, which met with their dietary needs and choices.
Environmental facilities provided sufficient space, relevant aids and adaptations for people to move around safely and as independently as possible. People were comfortable and satisfied with their own rooms, which they could personalise to their own taste.
Staff understood and promoted the principles of equality, dignity, choice and rights when they provided people’s care. Staff were kind, caring and compassionate and had established good rapport and relationships with people and their relatives.
People and relatives were informed and involved in agreeing care and daily living arrangements at the service and to access independent advocacy to speak up on their behalf if needed.
People received timely individualised care, which met with their daily living and lifestyle preferences. People were supported to engage in home life and with the local community as they chose.
Staff knew people well; they were mindful of people’s needs and knew how to support and communicate with them in a way that was meaningful and helpful to them.
Staff were trained and followed recognised principles to support people’s end of life care when needed, through partnership working with external health professionals.
People were informed of how to make a complaint if they needed to and the provider regularly sought people’s views about the service. This was used to inform and make care improvements when required.
The home was well managed and led with consistent provider oversight to help ensure this. Improvements were made for the consistent management, monitoring and oversight of the service to ensure the quality and safety of people’s care and to help drive ongoing service improvement.
Staff understood their role and responsibilities for people’s care; and they were confident and knew how to raise any related concerns if they needed to.
Communication and record keeping procedures at the service met with nationally recognised guidance concerned with information handling and confidentiality.
The provider had conspicuously displayed their most recent inspection report at the service and on their website; thereby following legal requirement.