CQC report explained · a residential care home
What the CQC found at Southfields House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Staffing levels, safeguarding, risk management, infection control and medicines were found to be effective.
- Effective?
- Good
- People's needs were assessed before moving in and staff had suitable training and support. People received food, drink and healthcare support suited to their needs.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were involved in decisions and supported to remain as independent as they wished.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People had access to activities, support to keep relationships and a clear complaints process.
- Well-led?
- Good
- Inspectors found an open and person-centred culture. The home used audits, feedback and partnership working to monitor and improve care.
What inspectors found, September 2023
Rated Good; inspectors found safe, kind and personalised care, with improvement since the previous rating of Requires Improvement.
Inspectors visited without notice on 15 June 2023. They spoke with 8 people, 9 relatives and 9 staff. They reviewed care records, medicines records, staff files, training information and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives described the care positively. Inspectors found that staff knew people well, treated them with dignity and supported their choices, health needs, relationships and interests.
Staffing, medicines, safeguarding and infection control were found to be managed safely. Care plans included people's needs and risks. The home had systems for complaints, learning from incidents and checking the quality of care.
Safe staffing
Inspectors found enough staff to meet people's needs safely and on time. People and relatives also said staff were available when needed.
“Staffing levels were appropriate to ensure people's needs were met in a safe, timely and consistent way.” from the report
Medicines
Medicines were stored and given safely. Records showed that people received their medicines as prescribed.
“Medicine administration records (MARs) were completed accurately and showed people received their medicines as prescribed.” from the report
Kind and respectful care
Staff understood people's individual needs and treated them with dignity. Inspectors observed respectful and friendly interactions.
“People were well treated and supported by staff who respected people's individuality and differences.” from the report
Activities and relationships
People were offered a range of activities inside and outside the home. Staff also supported contact with relatives and friends.
“People were offered the opportunity to join in with a variety of planned activities both in and out of the home.” from the report
Management and checks
The home had regular checks of care records, medicines, staff files and other records. People, relatives and staff felt able to give feedback.
“There was a comprehensive and effective governance system in place.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and update my relative's care plan and risk assessments after they move in?
- 02How will you make sure my relative receives medicines on time, including any medicines prescribed to be taken as needed?
- 03Which activities would match my relative's interests, mobility and communication needs?
- 04How will you keep me informed if my relative becomes unwell or needs a healthcare appointment?
- 05What changes were made after the previous infection prevention and control concerns, and how do you check that these arrangements remain effective?
This was an unannounced inspection of all five CQC key questions, including infection prevention and control under Safe; the report describes this as the first inspection of the newly registered service. This explanation was written from the published report of 6 September 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, February 2022
Inspected but not rated; inspectors found serious infection-control shortfalls, alongside safe medicines and safeguarding practices.
This was an unannounced inspection on 17 and 18 January 2022. It began as a targeted visit after concerns about infection control, then widened to a focused inspection of Safe and Well-led. People were isolating during a COVID-19 outbreak, so inspectors could not speak to them directly. They observed care, spoke with relatives and staff, and checked care, medicines, recruitment and management records.
The provider was not following all infection-control guidance. Inspectors found problems with isolation arrangements, cleaning toilets and communal areas, staff clothing and bins for used PPE. They said this placed people at risk of infection and found a continued breach of Regulation 12.
There were also staffing vacancies, with agency staff and managers covering care shifts. This meant some planned audits had not been completed. Inspectors found that medicines, safeguarding, risk assessments and recruitment were generally managed appropriately.
The service was inspected but not rated because this was the first inspection of the newly registered service and not all five key questions were looked at. The previous provider had been rated Requires Improvement, but that was not reviewed as part of this inspection.
Safeguarding
Staff understood how to recognise and report abuse or improper treatment. Safeguarding alerts had been raised appropriately.
“Permanent and agency staff had received training on safeguarding procedures.” from the report
Risk management
People's risks were regularly assessed and reviewed when their needs changed. Staff used care plans to guide them in reducing known risks.
“People's risks had been assessed and reviewed regularly or as their needs changed.” from the report
Person-centred care plans
Care plans reflected people's personalities, likes, dislikes and protected characteristics. Regular agency staff received extra training about the home's systems.
“The registered manager had ensured people's care plans were written in a person-centred way, taking into account their personalities, likes, dislikes and protected characteristics.” from the report
Infection control
seriousThe home did not consistently follow infection-control guidance. Inspectors found unsafe isolation arrangements, unreliable cleaning and unsuitable arrangements for disposing of used PPE.
“The provider failed to assess, prevent and control the spread of infections. This placed people at risk of harm.” from the report
Kitchenette risks
needs fixingInspectors found no risk assessments for people using kitchenettes containing hot appliances and unlocked cupboards with cleaning products. The manager acted promptly after this was raised.
“The provider did not have risk assessments for people accessing the kitchenettes where hot appliances were used, and cleaning products were stored in unlocked cupboards.” from the report
Incomplete infection audit
needs fixingThe infection-control audit did not identify that the provider's policies failed to follow all government guidance. Planned audits had also not been completed since November 2021.
“However, the infection control audit did not identify where the provider's policies did not follow all the government guidance.” from the report
- 01What changes have been made to isolation arrangements since the inspection, including bedroom doors and ventilation?
- 02How are toilets, communal areas and bedrooms cleaned between uses and every day?
- 03Have the new hands-free PPE bins been delivered, and how are used PPE and soiled incontinence pads disposed of safely?
- 04How many care staff vacancies remain, and how are agency staff being trained and supervised?
- 05Have all planned quality and infection-control audits restarted, and what did the latest audit find?
This was a focused inspection of Safe and Well-led after infection-control concerns; Effective, Caring and Responsive were not inspected and the service was not rated overall. This explanation was written from the published report of 26 February 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 Southfields House
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- September 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- April 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021
Registered with the Care Quality Commission on 1 April 2021.
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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