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CQC report explained · a residential care home

What the CQC found at South Highnam

Goodpublished 15 August 2025, 13 months ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The latest report, explained

What inspectors found, March 2023

Rated Requires Improvement; inspectors found kind care but unsafe record keeping, risk assessments and quality checks.

This was an unannounced focused inspection. Inspectors visited on 24 and 31 January 2023, spoke with people, relatives, an advocate, staff and professionals, and checked care, medicines and management records.

The home provided kind and compassionate care. It was clean, well equipped and well maintained. Staff understood people's communication needs, supported decision-making and helped people access health and social care services.

However, medicines records and risk assessments were not always accurate or complete. Quality checks had missed these problems. Staffing usually met daily care needs, but people could not always go out when they wanted.

The overall rating changed from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. This was a focused inspection of those two areas, so the other areas were not inspected during this visit.

What inspectors praised
  • Kind and respectful care

    Inspectors found that staff were kind, compassionate and respectful. Staff understood people's individual needs and communication methods.

    “People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
  • Safeguarding understanding

    Staff had training about abuse and knew how to report concerns. The home worked with other agencies to protect people.

    “Staff had training on how to recognise and report abuse and they knew how to apply it.” from the report
  • Positive management culture

    Staff and relatives described managers as approachable and supportive. The manager responded promptly to feedback and began making changes during the inspection.

    “Management were visible in the service, approachable and took a genuine interest in what people, staff, family, advocates and other professionals had to say.” from the report
What inspectors were concerned about
  • Medicines records and checks

    serious

    Some medicines were out of date or no longer prescribed. Records and guidance for creams, variable doses, reviews and monitoring were incomplete or inaccurate.

    “Medicines were not always managed safely.” from the report
  • Risk information

    serious

    Risk assessments were not always completed or reviewed. Inspectors found no detailed diabetes risk assessments, leaving staff without important information about possible warning signs.

    “Risk assessments were not always completed. The assessments that were in place had not been regularly reviewed.” from the report
  • Quality monitoring

    serious

    The home's audits had not identified all the problems found by inspectors. Care records did not always contain enough information for staff to support people safely.

    “The provider had failed to complete effective audits or keep comprehensive records.” from the report
  • Access to outings

    needs fixing

    Staffing was enough for daily care, but not always enough for people to go out whenever they wanted. The report recommends reviewing staffing against people's individual support needs.

    “there were not always enough staff on duty for people to go out whenever they wanted.” from the report
Questions to ask them, based on this report
  1. 01How have you corrected the medicines records, including records for creams, variable doses, reviews and monitoring?
  2. 02Have all people's risk assessments been completed and regularly reviewed, including diabetes risks and signs of high or low blood sugar?
  3. 03What checks now make sure medicines and care records are accurate and complete?
  4. 04How will staffing support people to go out both on planned trips and when they want an unplanned outing?
  5. 05What actions were included in the provider's action plan, and what progress has been made since the inspection?

This was a focused inspection of Safe and Well-led only; the other areas were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 7 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

An earlier report, explained

What inspectors found, April 2022

Inspected but not rated; inspectors found good infection control during a targeted COVID-19 review.

The home provides accommodation and personal care for up to eight people with autism and learning disabilities. Seven people were living there when inspectors visited.

This was an announced, targeted inspection on 9 February 2022. Inspectors looked at infection prevention and control, and asked about staffing pressures linked to COVID-19.

Inspectors were assured that the home used PPE safely, supported testing, managed visitors, and followed shielding and social distancing rules. They also found the home clean and well ventilated, with frequent cleaning of high-touch surfaces.

The home was inspected but not rated. This means the inspection did not give a graded rating for the service.

What inspectors praised
  • Clean environment

    The home was clean and well ventilated. Staff regularly cleaned surfaces that people touched often to reduce infection risks.

    “The home was clean and well-ventilated. Staff frequently cleaned high touch surfaces to reduce the risk of spreading any infections.” from the report
  • Infection control

    Inspectors were assured that the home had arrangements covering PPE, testing, admissions, visitors and outbreak management.

    “We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
  • Support for understanding

    Staff used creative approaches to help people understand COVID-19 and encouraged handwashing.

    “Staff used creative ways to help people understand COVID-19 and to promote handwashing.” from the report
  • Visiting arrangements

    The home followed procedures for visitors and was meeting the vaccination requirement applying to visiting professionals at that time.

    “The service followed robust procedures for those visiting the service including ensuring that visiting professionals were vaccinated against COVID-19.” from the report
What inspectors were concerned about

Inspectors raised no specific concerns in this report.

Questions to ask them, based on this report
  1. 01How are you managing any current staffing pressures, and have these affected people living in the home?
  2. 02How do you currently arrange visits from family members and visiting professionals?
  3. 03How do you provide PPE and infection control training to staff?
  4. 04How often are people living here and staff tested for infections?
  5. 05How do you keep the infection prevention and control policy up to date?

This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it did not provide graded ratings for the other areas of care. This explanation was written from the published report of 2 April 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of South Highnam

4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.

  1. March 2023Requires improvementcurrent rating
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at South Highnam →

  2. April 2022Inspected but not rated
    Safe: Inspected but not rated

    Read what inspectors found at South Highnam →

  3. April 2020Goodstayed Good
    Safe: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. August 2017Goodstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  5. June 2015Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  6. May 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. June 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. March 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. March 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  10. December 2010

    Registered with the Care Quality Commission on 20 December 2010.

Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.

Next steps

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