CQC report explained · a nursing home
What the CQC found at Southdowns Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Southdowns Nursing Home was rated Requires Improvement; inspectors found risks and record-keeping were not always managed safely.
This was an unannounced focused inspection on 29 June, 03 July and 04 July 2023. One inspector reviewed records, medicines, recruitment checks and the building. They observed communal areas and spoke with people, staff, visitors, relatives and health professionals.
The home was not always safe. Wound care, unexplained injuries, changes in behaviour and staff deployment were not managed consistently. Some people had to wait for help, and one communal area was left without staff presence, drinks or a call bell for part of the inspection.
The home was also not always well-led. Audits did not find important risks, and care records did not always contain complete information. The provider made some changes during the inspection, including new systems for recording injuries and reviewing wound care.
The overall rating changed from Good at the previous inspection to Requires Improvement. The inspection looked only at Safe and Well-led. The other question ratings were carried over from the previous inspection.
Safeguarding
Staff understood how to recognise and report abuse. Inspectors found that safeguarding referrals were made when needed.
“People were protected from risk of abuse by organisational systems and processes.” from the report
Medicines
Medicines were stored, given and disposed of safely. Staff who administered medicines had the required knowledge, training and competency.
“Medicines were stored, administered, and disposed of safely.” from the report
Suitable recruitment
The home completed recruitment checks before staff started work, including criminal record checks and checks on nurses' registration.
“Recruitment checks were carried out before staff started work at Southdowns Nursing Home.” from the report
Working with professionals
Staff worked with health and care professionals, including therapists and community teams, to support people's needs.
“They contact us in a timely way and work with us.” from the report
Wound care and injury risks
seriousWounds were not always assessed or recorded fully, and staff did not always follow recommended guidance. Injuries and unexplained bruising were not consistently investigated to prevent them happening again.
“The impact of these shortfalls meant people were at risk of wound deterioration.” from the report
Incomplete care records
seriousRecords did not always explain changes in people's health, behaviour or care needs. This meant staff, including new or agency staff, might not have the information needed to provide safe care.
“There was a lack of clear and accurate records regarding some people's care and support.” from the report
Staff deployment
needs fixingAlthough staffing numbers were considered appropriate overall, staff were not always positioned where people needed them. This led to delays and left one communal area without adequate support during the inspection.
“There was a lack of staff presence in the first-floor communal area between 11 am and 11 40 am.” from the report
Personal care
needs fixingPeople were not always offered showers or oral and personal care consistently. Records did not always show whether care had been attempted or why it could not be provided.
“Oral health care support and personal care was not being given consistently.” from the report
Infection control practice
needs fixingThe home was visually clean, but there were unpleasant odours in some areas. Staff were not always following good practice for gloves and moving soiled linen.
“It was identified during the site visit that staff were not following good practice guidance regarding gloves and transporting soiled linen.” from the report
- 01What changes have been made to wound assessments and treatment records since the inspection?
- 02How are unexplained bruises, skin tears and other incidents now investigated and reviewed for patterns?
- 03How do you make sure staff are present in communal areas and that people can get drinks and use a call bell?
- 04How are care records updated when someone's behaviour, health or personal care needs change?
- 05Who is currently responsible for managing the home, and how are leadership and quality checks being overseen while there is no registered manager?
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 July 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, March 2021
Inspected but not rated; inspectors were assured about infection prevention and control at Southdowns Nursing Home.
This was an announced, targeted inspection on 12 February 2021. It focused on infection prevention and control because the home had experienced a coronavirus outbreak.
Inspectors found that the home had systems for isolating people, reducing infection risks, cleaning, using protective equipment and carrying out testing. They were assured that the provider was meeting the infection control measures they checked.
The home was closed to most visitors at the time, except for people visiting someone receiving palliative or end of life care. Families could keep in touch through phone and video calls, and a separate visiting room with a large window had been built.
The service was inspected but not rated. This report does not give ratings for the other four areas of care.
Infection control planning
The home used bedroom isolation and zoning to reduce the risk of infection spreading. Its plans had been updated after experience of an outbreak.
“The contingency plan demonstrated that the layout of the premises allowed zoning to reduce risk of Covid-19 spreading.” from the report
Cleaning and hygiene
The home was clean and well maintained. Cleaning took place regularly, including on frequently touched areas.
“The home was clean and well maintained. There was regular cleaning throughout the day and this included high-touch areas.” from the report
Protective equipment and testing
Staff had supplies of protective equipment and training in how to use it. The report also describes regular testing and health checks for staff and residents.
“Staff had received specific Covid-19 training, and this included guidance for staff about how to put on and take off PPE safely.” from the report
Keeping families in touch
While most visits were stopped, staff supported people to use phone and video calls. The home had also created a separate visiting room for safer family contact.
“Staff supported people to remain in contact with their families through a secured Facebook page, and phone and video calls at this time.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current visiting arrangements, and is the separate room with a large window still available?
- 02How would the home isolate residents and organise staff if there were another infection outbreak?
- 03How often are residents and staff tested now, and what other health checks are carried out?
- 04How will the home help my relative keep in contact with family if visits are restricted?
- 05How often are high-touch areas cleaned, and how is staff use of protective equipment checked?
This was an announced, targeted inspection of infection prevention and control only; the service was inspected but not rated and the other areas were not assessed in this report. This explanation was written from the published report of 6 March 2021 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 Southdowns Nursing Home
5 rated inspections over 8 years: the service has improved, from Inadequate to Requires improvement.
- July 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- December 2019Goodstayed GoodSafe: GoodWell-led: Good
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2015InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 4 February 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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