CQC report explained · a nursing home
What the CQC found at Southcrest Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2020
Southcrest Nursing Home was rated Requires Improvement; inspectors found safe, kind care but activities, care records and management checks needed further work.
This was an unannounced inspection over 26 and 28 November 2019. Inspectors spoke with people living at the home, relatives, staff and managers. They observed care and checked care plans, medicines, recruitment, incident records and safety records.
The home was rated Good for safe, effective and caring services. People were protected from abuse, medicines were administered by trained staff, and staff supported people's health, eating, drinking and choices. Inspectors also found improvements since the previous inspection, including better infection control and stronger support for people's rights under the Mental Capacity Act.
The home was rated Requires Improvement for responsive and well-led services. Some care records were not fully accurate or personalised. Activities were limited and were not clearly based on people's interests. Management systems had improved, but inspectors said further work was needed to make improvements consistent and lasting.
People felt safe
People told inspectors they felt safe. Staff knew how to recognise and report abuse, and staffing levels were reviewed against people's needs.
“People's safety was protected from abuse by staff who knew what procedures to follow to keep people safe from harm.” from the report
Kind and respectful care
Staff treated people with dignity and respect. They protected privacy, supported independence and involved people in everyday choices.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Improved staff training
Staff received induction, training, supervision and support. The home had improved how it recorded and monitored staff training since the previous inspection.
“Staff had received the training and support they needed to be effective in their roles.” from the report
Support with health and nutrition
Staff helped people eat and drink safely and worked with healthcare professionals when concerns arose. People were supported to access doctors and other health professionals.
“People received the support they needed to have enough to eat and drink.” from the report
Limited activities
needs fixingInspectors found that opportunities for hobbies and social activities needed to improve. Activities were limited and it was unclear whether they were based on people's interests.
“At this inspection we found the opportunities for people to take part in following their interests and take part in activities they found interesting and enjoyable needed to be improved further.” from the report
Care records needed more detail
needs fixingSome records did not give a fully accurate or personalised account of people's care. One person's daily records contained conflicting information about food and preferences.
“Some areas of care documentation which required further development to ensure they were accurate to promote consistency in responding to people's needs.” from the report
Management checks needed strengthening
minorThe home had improved its quality systems, but inspectors said some improvements were not yet embedded. Daily cleaning checks were not as effective as they could be.
“At this inspection whilst some improvements had been made these needed to be embedded in the culture of the home.” from the report
- 01What activities are now available, and how do you record and review whether they match each person's interests?
- 02How do you check that care plans and daily records are accurate, personalised and up to date?
- 03What changes have been made to strengthen quality checks, including cleaning checks?
- 04How do you make sure agency staff follow each person's individual care guidance?
- 05How are decisions about giving medicines covertly discussed with the person's representative, GP and pharmacist?
This was a planned, unannounced inspection covering all five CQC questions, with ratings for safe, effective, caring, responsive and well-led services. This explanation was written from the published report of 17 January 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.
What inspectors found, December 2018
Rated Requires Improvement; inspectors found kind care but repeated shortfalls in safety, records, staff support and management.
Inspectors visited on 9 and 12 November 2018. The first visit was unannounced. They spoke with people, relatives, staff and health and social care professionals. They reviewed care records, medicines records, staff files, complaints and quality checks.
The home cared for 28 older people, some living with dementia, in accommodation registered for up to 40 people. Inspectors found staff were generally kind, helpful and attentive. People were supported with food, drinks, health appointments and identified eating and drinking risks.
However, several important areas needed improvement. Shared hoist slings were not always cleaned between people. Some risk plans and medicine instructions were unclear. Care records were not always accurate or personalised, and confidential information was left unsecured.
The overall rating was Requires Improvement. Safe, caring and responsive remained Requires Improvement from the previous inspection. Effective and well-led fell from Good to Requires Improvement. This was the second consecutive comprehensive inspection with an overall Requires Improvement rating.
Kind staff
People, relatives and professionals described staff as kind, respectful and attentive. Inspectors also saw caring interactions during their visits.
“During our inspection visits, we saw a number of caring interactions between individual staff and the people who lived at the home.” from the report
Food and fluids
People were offered choices and received help to eat and drink safely. The home assessed complex eating and drinking needs and followed specialist advice.
“We saw mealtimes were unrushed and social events, during which people were provided with any physical assistance needed to eat safely and comfortably.” from the report
Health support
Staff monitored changes in people's health and helped them access community healthcare. Relatives gave positive examples of staff responding to health concerns.
“They actively monitor [person's] health…” from the report
Approachable management
People, relatives and staff said the management team was approachable and listened to their views. Staff said they felt valued and supported.
“Both nurses and care staff felt well-supported by an approachable management team who were supportive, willing to listen and who valued their individual opinions and efforts.” from the report
Infection control
seriousShared hoist slings were not always cleaned between uses for different people. The manager said that named slings would now be used and cleaned appropriately.
“staff informed us hoist slings, which were shared amongst the people who lived at the home, were not always cleaned in between using them for different people.” from the report
Unclear safety plans
seriousA person's risk plan did not clearly explain how to prevent them leaving unnoticed. The front door had not been fully risk assessed and was sometimes left open.
“The front door isn't always locked. Some residents have dementia, and that could be an issue.” from the report
Medicine instructions
seriousSome PRN medicine guidance was incorrect or unclear. One person's regular use of an anxiety and insomnia medicine was not clearly recorded or monitored.
“Their 'PRN protocol' referred to the incorrect dosage of this medicine and did not clarify the specific circumstances in which it should be used.” from the report
Staff support and training
needs fixingStaff had not consistently completed Care Certificate induction training. Regular supervision and appraisal had lapsed, including clinical supervision for nurses.
“staff supervision and appraisal had lapsed since the start of this year.” from the report
Care records and activities
needs fixingCare plans were not always accurate or personalised. People and relatives had mixed views about whether activities supported their interests, and no structured activity took place on one inspection day.
“the information in people's care plans was not always accurate or sufficiently personalised, and included little information about people's known wishes and preferences.” from the report
Confidential information
seriousConfidential day-to-day care information was left unsecured in a communal dining room. This breached people's right to privacy.
“A range of confidential information relating to people's day-to-day care, including staff's daily handover records, had been left unsecured in the ground-floor dining room.” from the report
- 01How are hoist slings now assigned, cleaned and checked between uses?
- 02What has changed to keep the front door secure and to reduce the risk of anyone leaving the home unnoticed?
- 03How do you check that PRN medicine instructions are correct, current and followed?
- 04Have all staff completed the required induction, supervision and appraisal? How is this recorded?
- 05How have care plans, activities and end-of-life preference records been updated to reflect each person's wishes?
This was a comprehensive inspection of all five key questions, prompted partly by information about possible risks, but it did not examine the specific allegations because they were under local authority investigation. This explanation was written from the published report of 20 December 2018 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 Southcrest Nursing Home
6 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- January 2020Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- November 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 16 March 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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