CQC report explained · a nursing home
What the CQC found at Southerndown
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people were protected from avoidable harm. Medicines, safeguarding, accidents, infection control, recruitment and environmental risks were managed through suitable systems, although night call-bell response was being reviewed.
- Effective?
- Good
- People's care, health and nutritional needs were assessed and reviewed. Staff were trained and supported, and the home worked with healthcare professionals.
- Caring?
- Outstanding
- Inspectors found exceptionally kind, respectful and person-centred care. Staff promoted independence, involved people in decisions and built meaningful relationships with people and families.
- Responsive?
- Good
- Care plans reflected people's needs, routines and life histories. People had choices about activities, communication support and end of life care, and complaints were handled through a formal process.
- Well-led?
- Good
- The home had a supportive management structure, effective quality checks and an open culture. The manager worked with families, staff and outside professionals and submitted required notifications.
What inspectors found, July 2019
Southerndown was rated Good overall; inspectors found exceptionally caring support, with night call-bell response being reviewed.
This was an unannounced inspection on the first day of a two-day planned visit. Inspectors spoke with people, relatives, staff and outside professionals. They checked care records, medicines, recruitment, training and management records.
The home was rated Good for safe, effective, responsive and well-led care. It was rated Outstanding for caring. Inspectors found kind and respectful staff, personalised support, good healthcare and food arrangements, and systems that managed risks and medicines safely.
People were supported to make choices, stay independent and take part in activities. The home also supported people living with dementia and their families through a dementia specialist nurse, a family support group and a dementia care programme.
Kind and respectful care
Staff were consistently described and observed as gentle, patient and compassionate. People were treated with dignity and their privacy was respected.
“All the interactions we observed between staff and residents were courteous, gentle, patient and kind.” from the report
Dementia and family support
A dementia specialist nurse provided extra support to people and their families. Relatives could also attend a support group and ask questions about dementia.
“The provider also employed a dementia care specialist nurse who provided additional support to people living with dementia and their families.” from the report
Safe medicines and risk management
People received medicines as prescribed. Individual risks, such as weight loss, mobility and skin damage, were assessed and monitored.
“The records demonstrated people received medicines as prescribed.” from the report
Strong management checks
The management team used regular quality checks and monitored important clinical information. Staff described the culture as open and positive.
“The provider operated a structured approach to quality assurance that was effective in identifying and addressing any areas in a need of improvement.” from the report
Night call-bell response
needs fixingAlthough inspectors found enough staff to keep people safe overall, some people said call bells took longer to be answered at night. Management said night staffing levels were being reviewed.
“We however had mixed comments about night staffing levels, some people said that it took longer for a call bell to be answered during the night.” from the report
- 01What was the outcome of the review of night staffing levels and night-time call-bell response?
- 02How is the dementia care programme used now, and what support can the dementia specialist nurse offer to residents and families?
- 03How often are care plans reviewed, especially when someone loses weight, has a fall or develops another health risk?
- 04What was the outcome of the complaint that was still being investigated at the inspection?
- 05How will you maintain the same caring approach across both units and all staff teams?
This was a scheduled, planned inspection covering all five key questions, and both the premises and the care provided were looked at. This explanation was written from the published report of 24 July 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.
What inspectors found, November 2016
Rated Good; inspectors found safe, kind and responsive care, with some pressure mattress records and dementia-friendly features needing improvement.
The home provides nursing care and accommodation for up to 87 older people. There were 71 people living there during the unannounced inspection on 18 and 19 October 2016. Inspectors observed care, spoke with people, relatives, staff and outside professionals, and checked care, medicine, staff and quality records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines, suitable training, respectful care, detailed care plans, activities and systems for handling complaints and checking quality.
There were two areas to improve. Pressure-relieving mattresses did not have recorded guidance about the correct settings or regular checks. One part of the dementia unit was not very easy to navigate and had limited equipment to support people's senses and memories. The manager acted on the mattress issue after it was raised and had plans for refurbishment.
Infection control improved
The problems found at the previous inspection had been addressed. People needing hoisting had their own labelled slings and the sluice rooms were refurbished and kept tidy.
“At this inspection we found the provider had implemented the improvements required and we found sluice rooms were refurbished and were kept tidy.” from the report
Safe medicines
Inspectors observed medicines being given safely and found secure storage, appropriate temperature checks and no discrepancies with controlled medicines.
“We observed the administration of medicines and we saw that medicine was given to people in a professional and safe manner.” from the report
Kind and respectful care
Staff were warm, patient and respectful. They offered choices, supported independence and paid attention to people's individual preferences.
“There was clearly a genuine warmth and affection displayed by the staff.” from the report
Good activities and personal support
People could choose from activities such as quizzes, crosswords, music, pet therapy and trips. Staff also responded to individual health needs and worked with outside professionals.
“People could choose what activity to engage in.” from the report
Strong quality checks
The home used audits, meetings, feedback and action plans to monitor care and address issues.
“The provider had systems in place to monitor the quality of the service.” from the report
Pressure mattress records
needs fixingThere was no recorded guidance showing the correct setting for each pressure-relieving mattress, and no evidence of regular setting checks. This could have increased the risk of pressure sores. The manager arranged a review and later confirmed the information had been added where needed.
“This meant people could have been at risk of developing pressure sores.” from the report
Dementia-friendly environment
needs fixingOne floor of the dementia unit had bedroom doors that looked alike and only had very small name cards. There was also limited equipment to stimulate the senses and prompt memories. A refurbishment was planned.
“One floor on Memory Lane was not particularly dementia friendly.” from the report
- 01How are pressure-relieving mattress settings recorded and checked for each person now?
- 02Has the planned refurbishment of the dementia unit been completed, and what dementia-friendly equipment is now available?
- 03How do you maintain safe staffing levels when staff are off sick or on leave?
- 04How are people's individual preferences, health needs and activities kept up to date in their care plans?
- 05How do you use complaints, surveys and residents' meetings to make changes?
This was an unannounced inspection covering all five CQC questions, including observations, discussions with people and staff, and checks of care, medicine, recruitment and quality records. This explanation was written from the published report of 24 November 2016 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 Southerndown
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- July 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 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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