CQC report explained · a nursing home
What the CQC found at Southdown Nursing 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, May 2020
Southdown Nursing Home was rated Good overall, but inspectors found safety systems still needed improvement.
Inspectors visited unannounced on 3 and 4 February 2020. They spoke with people, relatives, staff and healthcare professionals. They looked at care plans, medicines records, staff files and other safety and training records.
The home had improved since its previous inspection. Chemicals and infection risks were being managed, medicines were handled safely, safeguarding concerns were dealt with properly and there were enough staff. However, some risk plans lacked detail, incidents were not always recorded consistently and recruitment paperwork needed minor improvement.
People received kind, respectful and personalised care. Their health, food, communication, cultural and end of life needs were considered. The home had regular checks and involved people, relatives and staff in making improvements.
The overall rating was Good. Safe remained Requires Improvement. Effective, Caring, Responsive and Well-led were all rated Good. This means inspectors found good care overall, but had limited assurance that every part of safety was consistently managed.
Enough staff
Inspectors found staffing levels were safe. Staff said they could get extra support in an emergency.
“Rotas showed there were enough staff to care for people safely, and this was calculated using a suitable staffing dependency tool.” from the report
Kind and respectful care
Staff understood people well and treated them with kindness, empathy and respect.
“People received care and support from staff who were kind and caring.” from the report
Personalised support
Care plans reflected people's preferences, backgrounds, communication needs and end of life choices.
“People's care plans were personalised and set out what help and support they needed and wanted with each aspect of their daily living.” from the report
Improved oversight
The provider had introduced regular checks covering medicines, infection control, food, records and the building.
“There was a range of regular audits, including medicines, infection control, food quality, care records and environmental safety, to enable the provider to monitor and improve the safety and quality of the service.” from the report
Risk plans lacked detail
needs fixingSome plans did not clearly explain how staff should manage risks such as falls and pressure ulcers. Inspectors said this could make safe care harder for staff who did not know people well.
“However, although some risk management plans were clear, others lacked detail about how to reduce risks such as people's risk of falls or developing pressure ulcers.” from the report
Incident records were inconsistent
needs fixingStaff did not always record injuries in incident forms as well as in care records. This could mean patterns were missed when reviewing risks or safeguarding.
“This meant there was a risk the provider was not including these incidents in their analysis of trends and therefore it may be missed when reviewing risk assessments or carrying out safeguarding investigations.” from the report
Recruitment paperwork
needs fixingThe provider had gathered required checks, but its application forms did not give enough space for some legally required information. There was no checklist to make sure this information was not missed.
“Because the provider did not use a checklist or other means of ensuring this information was supplied, this meant there was a risk this information could be missed.” from the report
Dementia-friendly refurbishment
minorSome areas still needed refurbishment. The plans had not fully met their timescales and did not specifically consider the needs of people living with dementia.
“The provider had further plans for this but had not met all of their targets in terms of timescales and the plans did not specifically look at the needs of people with dementia.” from the report
- 01How are risk plans for falls and pressure ulcers reviewed, and when were they last updated?
- 02How are incidents and injuries recorded, checked for patterns and used to change people's risk assessments?
- 03What checks now make sure recruitment forms include explanations for any gaps in employment?
- 04What is the timetable for the remaining refurbishment, and how will the design meet the needs of people living with dementia?
- 05What recent changes have been made in response to mixed feedback about food quality?
This was an unannounced planned inspection based on the previous rating and covered all five key questions; inspectors spoke with two people, three relatives, four staff and two healthcare professionals and reviewed selected records. This explanation was written from the published report of 15 May 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, October 2019
Southdown Nursing Home was rated Requires Improvement; inspectors found kind, personalised care but important safety and management systems were not reliable.
The inspection was unannounced and took place on 9 and 11 January 2019. Inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They also reviewed records, medicines, care plans, staffing and the building.
The home had improved since the previous inspection. There were enough staff, medicines were managed safely, risks were assessed, and people had access to food, activities and healthcare. Staff were caring and respectful, and care plans were more personalised.
However, inspectors found problems with infection control, the storage of chemicals, a broken floor tile and staff recruitment checks. Records did not always show that people had consented to their care. The home was still in breach of good governance rules because its checks did not reliably identify and fix problems.
Kind and respectful staff
Staff built positive relationships and gave emotional support. They respected privacy and encouraged people to remain as independent as possible.
“Staff were respectful and empathetic, giving people emotional support when they needed it and taking the time to build good relationships with them.” from the report
Personalised care
Care plans contained detailed information about people's health needs, preferences and how they wanted care delivered. People and relatives were involved in planning care.
“People had personalised care plans that took into account their diverse needs, preferences and wishes about how they wanted their care delivered.” from the report
Activities and community links
People could take part in group activities, one-to-one sessions, outings and visits from outside organisations. The home also worked with local community groups.
“People had access to a variety of activities inside and outside the home.” from the report
Infection control
seriousThere were no formal checks of cleanliness or infection control outside the kitchen. Inspectors saw stained bathroom surfaces and visibly dirty toilets.
“There were no formal checks of cleanliness or infection control audits.” from the report
Unsafe chemical storage
seriousCleaning products and other harmful chemicals were left in unlocked or accessible places. The provider moved them during the inspection, but its own checks had not found the problem.
“Chemicals were not always stored securely in line with control of substances hazardous to health (COSHH) guidance.” from the report
Consent records
seriousThe home could not always show that people had consented to their care. In some cases, records suggested relatives had signed instead, without evidence of a capacity assessment or best-interest decision.
“Appropriate processes were not always being followed in regards to MCA (Mental Capacity Act) assessments and best interest meetings.” from the report
Recruitment records
needs fixingFour of six staff files checked did not contain a complete employment history. This meant the home did not have all the information required to check staff suitability.
“Four of the six staff whose files we checked had not supplied a full employment history including dates” from the report
Repeated governance failures
seriousThe provider had improved some systems, but its checks continued to miss important problems. This was the sixth inspection since November 2015 where CQC found a breach related to governance.
“This is the sixth inspection since November 2015 at which we have judged the provider to be in breach of regulation 17” from the report
- 01What formal checks do you now use to monitor cleanliness and infection control in bathrooms and other parts of the home?
- 02How are cleaning products, bleach and other hazardous chemicals kept locked away at all times?
- 03How do you record a person's consent to care, and what do you do when someone may lack capacity to make a decision?
- 04Have all staff recruitment files been updated with complete employment histories and the other required checks?
- 05What changes have you made in response to the warning notice and the repeated governance concerns?
This was an unannounced inspection of the care, nursing and accommodation provided by the home, and it assessed all five CQC questions. This explanation was written from the published report of 15 October 2019 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 Southdown Nursing Home
11 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- May 2020Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2017Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2015Requires improvementstayed Requires improvementSafe: Good
- July 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 January 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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