CQC report explained · a residential care home
What the CQC found at Southbank
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- The home was no longer in breach of the safe care and treatment regulation, and improvements had been made to medicines, food storage and safety checks. However, fluid records and other care records were not always clear or complete, and some furniture was damaged or difficult to clean.
- Effective?
- Requires improvement
- This question was not inspected during this visit. Its previous rating was carried forward.
- Caring?
- Requires improvement
- This question was not inspected during this visit. Its previous rating was carried forward.
- Responsive?
- Requires improvement
- This question was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management and governance systems were still not strong enough. Improvements were not always given clear deadlines or named owners, and Regulation 17 remained breached.
What inspectors found, October 2023
Southbank rated Requires Improvement; inspectors found improvements in medicines and staffing, but records, premises and management systems still needed work.
This was an unannounced focused inspection. Two inspectors spoke with people, staff and visiting professionals. They reviewed care and medicine records and documents about how the home was managed.
The home had improved its medicine arrangements, food storage, safety checks and communication with health professionals. Staff knew people well, responded quickly and there were enough staff on duty. People said they felt safe and received their medicines as prescribed.
However, care records were difficult to follow, sometimes out of date and not always completed. The building and furniture were old and worn. Management checks did not always include clear deadlines or named people responsible for completing improvements. The home remained in breach of Regulation 17 for good governance.
The overall rating stayed Requires Improvement. This means the inspectors found some improvements, but there was not enough assurance that the home was consistently safe and well managed. The Safe and Well-led ratings were assessed at this inspection, while the other ratings were carried over from the previous inspection.
Enough staff
Inspectors found enough staff to meet people's needs and saw staff respond quickly when people needed help.
“There were enough staff on duty to meet people's needs and keep them safe.” from the report
Safer medicines
Medicine arrangements had improved. Staff were trained, followed safe administration practices and checked whether people needed prescribed medicines when required.
“People received their medicines in line with their prescription by staff who were trained to do so.” from the report
People felt safe
People told inspectors they felt safe. Staff understood safeguarding procedures and acted when concerns were raised.
“People told us they felt safe by the staff who supported them.” from the report
Improved communication
Visiting professionals said communication and staff knowledge of people's needs had improved since the previous inspection.
“Those we spoke with felt communication and staff's knowledge of people's needs had improved.” from the report
Care records were incomplete
needs fixingRecords were not always tailored to the individual, could contain out-of-date information and were sometimes hard to navigate. Daily records were not always completed, making it harder to confirm that risks and needs were being managed consistently.
“People's care records remained difficult to navigate, were not always individual to the person, held out of date information and daily records were not always completed.” from the report
Weak management oversight
seriousThe provider's checks identified problems, but actions did not always have clear deadlines or named people responsible. Some improvements remained incomplete for months.
“Without clear timescales and accountabilities, actions remained incomplete for months.” from the report
Worn building and furniture
needs fixingSome furniture was damaged, stained or difficult to clean. Fixtures and parts of the building needed replacement, and one person could not access the garden from their bungalow because of a step.
“The furniture and fixtures of the building were old and worn.” from the report
Unclear fluid monitoring
needs fixingSome records showed days when people had not drunk enough, but it was unclear whether records were incomplete or people had genuinely not had enough to drink.
“It was not clear if records were incomplete or the person had not drunk sufficiently.” from the report
- 01Which care records for my relative are out of date or difficult to follow, and when will they be corrected?
- 02How will you make sure daily records and fluid monitoring records are completed accurately every day?
- 03What is the timetable for replacing the damaged furniture and improving the building, including access to the garden?
- 04Who is responsible for each outstanding improvement, and how will you show that it has been completed?
- 05How will the change of manager affect the action plan and the oversight of care?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 25 October 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.
What inspectors found, January 2023
Requires Improvement; inspectors found risks in medicines, care planning and management systems that could put people at risk of harm.
Two inspectors visited on 11 and 12 October 2022. The first day was unannounced. They observed care, spoke with six relatives and 12 staff, and reviewed records and information from other organisations.
The home was not always safe, effective, caring or responsive. Medicines records were incomplete, some medicines were out of date, and care plans and risk assessments did not always reflect people's current needs. Inspectors also found concerns about dignity, activities, the condition of the building and the way the home was managed.
Inspectors found no evidence that people had been harmed, but said the systems were not strong enough to show that people were protected from harm. The home was rated Requires Improvement in all five areas. This was the first inspection since the current registration, and the rating remained the same as under the previous provider.
Safeguarding
Relatives said they felt their family members were safe. Staff knew how to recognise and report possible abuse, and recruitment checks were carried out.
“People were protected from the risk of abuse. People's relatives said they felt their family members were safe.” from the report
Communication support
People had communication plans, and staff understood individual communication needs. Support included Makaton, pictures and symbols.
“Staff had good awareness, skills and understanding of individual communication needs.” from the report
Choice and consent
People were supported to make some day-to-day choices. Staff sought consent and used body language where people could not give verbal consent.
“Staff took time to obtained people's consent before caring for them.” from the report
Activities and relationships
People were supported with some activities and community contact, including visits to a community farm, meals out, walks and socialising.
“This helped to reduce the risk of people experiencing social isolation.” from the report
Staff training
Staff had training in areas such as choking risks and seizure management. Agency staff seen by inspectors understood people's needs.
“People were supported by staff who had undertaken training to develop the skills and knowledge needed to care for people.” from the report
Out-of-date care plans and risk assessments
seriousCare plans and risk assessments were not always reviewed when people's needs changed. Staff therefore did not always have current guidance, including advice from health professionals.
“People's care plans and risk assessments did not always reflect their current needs and did not consistently promote their wellbeing.” from the report
Dignity and compassionate care
needs fixingSome staff did not always give people enough time to communicate or respond compassionately when they were anxious. People's privacy was not consistently respected.
“People were not always provided with compassionate and dignified care.” from the report
Building condition
needs fixingSome parts of the home needed refurbishment. Inspectors found damaged flooring and furnishings that needed replacing, with some areas needing urgent attention.
“The home was showing signs of wear and tear and some areas needed urgent attention to reduce the likelihood of accidents and injury.” from the report
Activities and community access
needs fixingRelatives gave mixed views about activities, and staff said community access was restricted by the small number of staff able to drive the minibus.
“Staff told us people's access to the community was restricted by the limited number of staff who could drive the minibus.” from the report
Weak management checks
seriousQuality checks did not identify several concerns found during the inspection. New auditing tools had been introduced, but inspectors said they were not yet used regularly enough or fully embedded.
“The quality assurance systems in place had failed to identify some of the concerns found on this inspection.” from the report
- 01How are you now checking that medicines are given as prescribed, records are signed and out-of-date medicines are removed?
- 02When was my relative's care plan and risk assessment last reviewed with them and their family?
- 03How do you check that weights, fluid intake and advice from health professionals are recorded and acted on?
- 04What has changed in management since the inspection, and how do you know the new audits are finding and fixing problems?
- 05How will you provide enough staff and transport access for my relative to take part in activities and go into the community?
This was the first inspection of the newly registered service and covered all five key questions, including infection prevention and control. This explanation was written from the published report of 11 January 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.
Every inspection of Southbank
2 rated inspections over a year: the service has held its Requires improvement rating throughout.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2023Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2022
Registered with the Care Quality Commission on 21 April 2022.
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.
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11 live-in carers within about an hour of Herefordshire, County of
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £960 to £1,410 a week. 10 can care for a couple. 8 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.