CQC report explained · a residential care home
What the CQC found at Southborough Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2022
Southborough Care Home was inspected but not rated; inspectors found good infection prevention and control arrangements during the COVID-19 pandemic.
This was an announced, targeted inspection on 24 February 2022. Inspectors checked infection prevention and control, including visitors, admissions, personal protective equipment, testing, cleaning and outbreak planning. They also asked about staffing pressures.
Inspectors were assured that the home was managing infection risks. The home was clean, people and staff had been vaccinated, and staff had training in protective equipment, hand hygiene and infection control. Isolation, zoning and grouping arrangements were being used effectively.
People were supported to keep in touch with relatives and friends through visits, video and telephone calls. The home had plans for outbreaks and staff absences. The service was inspected but not rated, so this report does not give an overall quality rating.
Infection control training
Staff had training in working during the pandemic, using protective equipment, hand hygiene and infection control.
“Staff had received training on working during the pandemic in relation to COVID-19 and had received training in the correct use of personal protective equipment (PPE), hand hygiene and infection control awareness.” from the report
Managing infection risks
The home used isolation, grouping and zoning arrangements effectively to help manage infection risks.
“The service used isolation, cohorting and zoning effectively.” from the report
Contact with relatives
People were supported to maintain contact through visits, video calls and telephone calls, including arrangements for essential visitors.
“People's wellbeing was supported by visits, video and telephone calls to relatives and friends.” from the report
Outbreak planning
The home had plans for managing a COVID-19 outbreak and possible staff absences.
“The registered manager had contingency plans in place to prepare for an outbreak and manage any staff absences effectively.” from the report
Further development suggested
minorInspectors signposted the provider to resources to develop its approach. The report does not explain what specific changes were needed.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01How do you currently manage COVID-19 or other infection outbreaks, including isolation, zoning and testing?
- 02How do you manage staffing pressures if staff are absent because of illness or infection?
- 03How is the infection prevention and control policy being reviewed for staff in vulnerable groups?
- 04How are visits, outings and essential visits at the end of life arranged under your current policy?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it did not rate the other five areas of care. This explanation was written from the published report of 10 March 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.
What inspectors found, July 2020
Inspected but not rated; inspectors found a safeguarding breach and staffing needed review, although infection control was being followed.
This was an unannounced, targeted inspection on 23 June 2020. Inspectors followed up concerns about staffing, safeguarding and infection control. They spoke with 10 staff members, reviewed information and observed care from 6am.
People were generally protected from infection. The home was clean, staff had protective equipment and staff followed current infection prevention guidance. However, staffing levels were not enough at some key times, and one person waited an hour for breakfast and a drink.
Inspectors found that safeguarding concerns were not managed effectively. A staff member under investigation had returned to work before external investigations were complete and was sometimes left unsupervised. This placed people at potential risk of harm and breached Regulation 13.
The service was inspected but not rated. The previous rating was Good, but this targeted visit did not assess all areas or change the earlier rating. CQC said it would continue monitoring the home.
Infection control
The home was clean, staff had protective equipment and staff followed the latest infection prevention guidance during the inspection.
“Other areas in the service were clean and staff had access to hand washing facilities.” from the report
Clean laundry area
Inspectors found the laundry room very clean, with separate baskets for clean and soiled laundry.
“The laundry room was very clean. There were separate baskets for soiled and clean laundry” from the report
Staff feedback
Staff gave positive feedback about how the service was managed.
“We received positive feedback from the staff team about the management of the service.” from the report
Safeguarding arrangements
seriousA staff member involved in an allegation returned before external investigations were complete and was sometimes working unsupervised. Inspectors said this placed people at potential risk of harm.
“This placed people at risk of harm. This was a breach of regulation 13” from the report
Staffing at busy times
needs fixingThere were not enough staff at some key times. Two night staff worked beyond their shifts, and one person waited an hour for breakfast and a drink.
“This demonstrated the number of staff was not enough at key times of the day.” from the report
Choice about getting up
needs fixingNight staff aimed to have everyone up by 7am, but there was no system to check whether this suited each person.
“There was no system in place to review if this was appropriate for each individual person.” from the report
Laundry bins
minorThe bins for soiled laundry did not have lids, creating a stated risk of cross infection, although inspectors found other infection control arrangements were being followed.
“the bins for soiled laundry did not have lids on to prevent risk of cross infection.” from the report
- 01What safeguards are now used if a staff member is under investigation for an allegation?
- 02How do you make sure a staff member under investigation is not left alone with residents?
- 03What changes have you made to staffing levels at breakfast and other busy times?
- 04How do you check that residents can choose when they get up?
- 05Have the bins for soiled laundry been fitted with lids?
This was a targeted inspection of specific concerns about staffing, safeguarding and infection control; it did not assess all five key questions or change the previous ratings. This explanation was written from the published report of 28 July 2020 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 Southborough Care Home
2 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- July 2020Inspected but not ratedSafe: Inspected but not rated
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 7 August 2011.
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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