CQC report explained · a residential care home
What the CQC found at Southernwood House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely, and some records used to monitor risks were incomplete. There were enough staff, staff had suitable training, and risks to people had generally been identified.
- Effective?
- Good
- This key question was not assessed during this focused inspection.
- Caring?
- Good
- No current rating was given. Inspectors found a caring culture and kind relationships between staff and people living at the home.
- Responsive?
- Good
- This key question was not assessed during this focused inspection.
- Well-led?
- Requires improvement
- Medicines audits had not found repeated problems, including inaccurate stock counts and missing as-needed medicine protocols. Other audits were helping to identify and make improvements.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found ongoing medicines safety and audit failures, with the home still in breach of regulations.
This was an unannounced focused inspection on 10 May 2023. One inspector spoke with two people living at the home and several staff, observed care, and reviewed four care records, medicines records and management documents.
The main concern was medicines. Records did not always show accurately when medicines were given or how many were left. Some guidance for medicines taken as needed was missing. One staff member's medicines competency check was also overdue, although this was completed after the inspection.
The home had enough staff, staff had the training needed for safe care, and people said they felt safe and well cared for. The home was clean overall and infection control arrangements were mostly satisfactory, although the laundry was untidy and cramped.
The overall rating stayed at Requires Improvement. Safe and well-led were both rated Requires Improvement. This was the third consecutive inspection with that overall rating, and the provider remained in breach of regulations about safe care and treatment and good governance.
Kind relationships
People said staff were kind and that they received help when they needed it. Inspectors saw that staff knew people well.
“The culture in the home was caring and staff focused on providing care which met people's needs.” from the report
Some effective improvement work
Audits about cleanliness, falls and nutrition identified actions, which were reviewed by the provider. The manager also worked with health and social care professionals on safety issues.
“Other audits were effective at driving and maintaining improvements in the home.” from the report
Medicines were not always safe
seriousMedicine records were inaccurate, some as-needed medicines lacked protocols, and patch records were not completed as required. This put people at risk of medicine errors and led to a breach of Regulation 12.
“Systems to ensure medicines were safely managed were not followed.” from the report
Medicines audits missed repeated problems
seriousAudits had failed to identify ongoing issues over three inspections, including inaccurate stock counts and missing as-needed medicine protocols. This led to a breach of Regulation 17.
“Audits to identify issues with medicines were not effective for the last three inspections.” from the report
Some care records were incomplete
needs fixingFluid intake was not recorded well enough to show that people were being offered enough to drink. Accident and incident information was not analysed for trends.
“fluid intake was not well recorded meaning we could not be sure people were being offered enough to drink.” from the report
Laundry area needed attention
minorThe inspection found the laundry was still untidy and cramped, although other infection prevention arrangements were considered satisfactory.
“We were assured that the provider was promoting safety through the layout and hygiene practices of the premises. Laundry still untidy and cramped.” from the report
- 01What has been done to make sure every staff member administering medicines has a current competency check?
- 02How are you checking that medicine records accurately show when medicines were given and how many remain?
- 03What guidance is now in place for medicines prescribed to be taken as needed?
- 04How are fluid intake records and accident and incident trends being reviewed?
- 05What action has been taken to improve the untidy and cramped laundry area?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection, and the home care service was not reviewed. This explanation was written from the published report of 26 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, August 2022
Rated Requires Improvement; inspectors found progress, but medicines, infection control and some risk records were still not safe enough.
This was an unannounced follow-up inspection on 17 May 2022. Inspectors spoke with people and staff, observed care, and checked care plans, medicines records, staff files and management records.
The home had improved its management of risks, medicines and infection control since the previous inspection. However, medicines were not always recorded or checked correctly. Some parts of the home were not clean enough, and risk information for people receiving care in their own homes was incomplete.
There were enough staff, and staff had the training to support people safely. People said they felt safe, could raise concerns, and were positive about the care. The service was still rated Requires Improvement because the provider remained in breach of Regulation 12.
Enough staff
Inspectors found enough staff to meet people's needs. Staff recruitment checks were also in place.
“There were enough staff to meet people's needs.” from the report
Safeguarding improved
The service was no longer in breach of the safeguarding regulation. Staff knew how to report concerns and legal authorisations were in place where needed.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 13.” from the report
People felt comfortable
People said they felt safe and could speak to staff or managers if they had concerns.
“People were positive about the home and quality of care provided.” from the report
Management systems improved
Audits and action plans had been introduced to identify and address a range of issues.
“At this inspection the registered manager had improved the management systems in the home.” from the report
Medicines and infection control
seriousMedicine records were not always accurate or regularly checked. Inspectors also found dirty bedding, cobwebs and other areas needing better cleaning.
“The provider had not ensured medicines were safely managed or that the environment supported good infection control.” from the report
Incomplete risk information
seriousCare plans for people receiving care in their own homes did not fully explain their risks or what staff should do if a condition worsened. Moving and handling skills had not been assessed for some staff.
“However, the care plans for people who received care in their own home lacked personalised information on risks to keep them safe.” from the report
Audits did not find everything
needs fixingSome audits missed problems because they did not include all relevant best practice. The provider was asked to review the audit system.
“However, some audits did fall short in identifying some of the concerns we found.” from the report
Limited incident analysis
needs fixingThe service recorded individual incidents and acted on them, but did not analyse incidents over time. This could mean missed opportunities to improve.
“However, analysis of incidents over time was missing and so the registered manager may miss opportunities to improve the care provided.” from the report
- 01How are medicine records checked regularly, including controlled medicines and medicines used to thin blood?
- 02What action has been taken to improve cleaning in bedrooms, toilets and the laundry?
- 03How are risks assessed and recorded for people receiving care in their own homes?
- 04How do you check that staff have been assessed as competent in moving and handling?
- 05What changes have been made to the audit system since this inspection?
This was a follow-up inspection focused on Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 13 August 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.
Every inspection of Southernwood House
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- December 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.