Background to this inspection
Updated
22 April 2021
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 Care Act 2014.
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 an inspector and an assistant inspector.
Service and service type
Southfields House 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.
The service had a manager registered with the Care Quality Commission. 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.
Notice of inspection
We gave the service 24 hours’ notice of the inspection.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
During the inspection
We spoke with four people who used the service and six relatives about their experience of the care provided. We spoke with 10 members of staff including the area manager, registered manager, shift leaders, care workers and head cook.
We reviewed a range of records. This included three people’s care records and multiple records relating to pressure care and fluid intake. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.
Updated
22 April 2021
About the service
Southfields House is a residential care home providing personal and nursing care to 24 people aged 65 and over at the time of the inspection. The service can support up to 45 people.
People’s experience of using this service and what we found
Staff completed body maps where injuries and bruises on people had been identified and these were regularly reviewed. However, not all unexplained injuries and bruises had been investigated to identify the possible cause. Staff received training on safeguarding and understood how to recognise and report abuse.
People had individual risk's assessed with strategies in place to mitigate risks. However, staff did not always follow the strategies.
Staff demonstrated a knowledge of people’s care needs and how to keep them safe.
Checks were in place to ensure the environment was safe.
Medicines were administered and stored safely.
People were protected against infection. Staff wore appropriate personal protective equipment [PPE] and the home appeared clean.
Auditing and oversight of some care records required improvement.
People and relatives spoke positively about the care provided and people were supported to stay in contact with their loved ones.
Rating at last inspection (and update)
The last rating for this service was requires improvement (published 23 September 2020) and there were breaches of regulation identified. 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 and the provider was no longer in breach of regulations.
The service remains rated requires improvement. This service has been rated requires improvement for four consecutive inspections.
Why we inspected
We carried out an unannounced focused inspection of this service on 11 August 2020. Breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found. This included risks in relation to eating and drinking, pressure area care, hot water and fire. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and 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 and Well-led which contain those requirements.
We also checked whether the Warning Notice we previously served in relation to Regulation 17 (1) of the Health and Social Care Act (Regulated Activities) Regulations 2014 Good governance had been met.
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 coronavirus and other infection outbreaks effectively.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection.
We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Southfields House on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.