CQC report explained · a residential care home
What the CQC found at Southgarth Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected by safeguarding training, risk assessments, safe recruitment and staffing based on their needs. Inspectors noted that the fire risk assessment had not yet been updated and that there had been 15 medicine recording errors in the previous year.
- Effective?
- Good
- Care needs were assessed and reviewed regularly. Staff training had improved, people received suitable food and drink, and staff worked with health professionals to support people's healthcare needs.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff listened to people, supported their choices and encouraged independence.
- Responsive?
- Good
- Care plans were personalised, reviewed monthly and developed with people's involvement. People could receive visitors, take part in activities and receive support with end of life care where possible.
- Well-led?
- Good
- The manager provided good leadership and had plans for further improvements. Regular checks, provider visits and reviews of incidents helped the home monitor its quality.
What inspectors found, January 2020
Rated Good; inspectors found safe, kind and personalised care, with some fire safety work and medicine recording issues still being managed.
This was an unannounced planned inspection on 5 December 2019. One inspector spoke with eight people living in the home, seven relatives, seven staff members and two healthcare professionals. They also observed care and checked care records, recruitment files, training records, complaints and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were treated kindly, involved in decisions, supported with their health needs and given personalised care. Medicines were administered safely, staffing was based on people's needs and the home was clean.
There were some issues to keep under review. The fire risk assessment was still described as generic and inadequate, although other fire safety work had been completed and an alarm upgrade was booked. There had also been 15 medicine recording errors in the previous year, which the manager had addressed through supervision and retraining.
Kind and respectful care
People and relatives described staff as kind and caring. Inspectors saw staff respond promptly when people became distressed or uncomfortable.
“We saw many positive interactions between staff and people during our inspection.” from the report
Personalised support
People helped shape their care plans and daily routines. Staff knew people's preferences and supported their choices about meals, activities and how they spent their time.
“People were involved in making decisions about their daily lives, their care and changes being implemented in Southgarth.” from the report
Safe staffing and recruitment
Staffing levels were reviewed against people's needs. Recruitment checks included references and DBS checks, and agency staff were rarely used.
“Agency workers were only used as a last resort.” from the report
Good healthcare links
The home worked with GPs, district nurses and other healthcare professionals. Inspectors were told that healthcare staff were called promptly when needed.
“They told us the staff supported people well and they had always been called in to see people in a timely manner.” from the report
Activities and family contact
People could take part in varied activities and visitors were allowed at any time during the day. Families could also be supported to stay overnight when someone was very unwell or receiving end of life care.
“There was a range of activities people could participate in.” from the report
Fire risk assessment
needs fixingThe Fire Service had said the fire risk assessment was generic and inadequate. This had not been put right at the inspection, although the home was organising it and a follow-up visit was planned.
“The Fire Service had also recommended that the fire risk assessment for the premises was 'generic and inadequate'.” from the report
Medicine recording errors
needs fixingThere had been 15 medicine recording errors in the previous 12 months. The manager had responded with supervision and retraining, but families should ask what checks are now in place.
“In the last 12 months there had been 15 medicine recording errors.” from the report
Food temperature
minorOne person said food and drink served in their room often needed to be hotter. Other people spoken with were positive about the meals.
“One person who liked to have their midday meal in their room commented that food and drink often needed to be hotter.” from the report
- 01Has the fire risk assessment been updated since the inspection, and what happened at the planned Fire Service follow-up visit?
- 02Has the fire alarm system upgrade been completed?
- 03What checks are now used to prevent medicine recording errors?
- 04How are people's preferences about food temperature, especially meals served in bedrooms, recorded and followed?
- 05How will the planned improvements to the building and furnishings be completed and monitored?
This was an unannounced planned inspection that looked at the overall service and all five CQC questions; all five ratings remained Good. This explanation was written from the published report of 11 January 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, June 2017
Rated Good; inspectors found safe, kind and well-managed care, with improvements since the previous inspection.
Inspectors visited on 18 and 20 April 2017. The first visit was unannounced. They spoke with people, a visitor, staff and a health professional. They also observed care and checked care records, medicines records, staff files and quality checks.
The home was rated Good overall and Good in all five areas. People were treated with kindness and respect. Their risks, medicines, health needs and day-to-day choices were generally managed well. The home was clean, homely and had enough staff to meet people's needs.
At the previous inspection in November 2015, safety required improvement because hot water could cause scalds. This inspection found that thermostatic mixing valves and individual risk assessments had been put in place, so the earlier legal requirement had been met.
Hot-water safety improved
The earlier risk from hot water had been addressed. Valves and checks were in place to reduce the risk of scalds.
“This meant people were kept safe from the risk of scalds from hot water outlets” from the report
Kind and respectful care
Staff knew people well and supported them with dignity, privacy and choice. People and relatives were very positive about the care.
“Staff treated people with kindness and compassion in everything they did.” from the report
Good health support
Staff monitored people's health and made prompt referrals when needs changed. Health professionals said concerns were escalated appropriately.
“They escalate concerns appropriately and in a timely manner, they follow given advice, and discuss concerns readily.” from the report
Visible leadership
The registered manager and deputy manager were closely involved in day-to-day care. Staff felt supported and were involved in reviewing the service.
“Leadership at the home was very visible; the registered manager was in day to day charge supported by the deputy manager.” from the report
Clean and homely setting
The home was clean, safe and welcoming. Emergency plans, fire checks and equipment checks were in place.
“The home was clean throughout without any odours present and had a pleasant homely atmosphere.” from the report
Some as-needed medicine guidance needed review
needs fixingSome protocols for medicines given when needed were in place, but the home was still checking that every such medicine had suitable guidance.
“During the inspection the registered manager allocated responsibility to a senior care worker to undertake a review and ensure all PRN medicines had an appropriate protocol in place.” from the report
Power of attorney details were unclear
needs fixingRecords did not clearly show what decisions some relatives with lasting powers of attorney could make. The manager said this information would be added to care records.
“However it was not clear which LPA relatives held, whether they could make decisions about their care and treatment and/or financial matters.” from the report
Activities and some decoration were being developed
minorThe provider identified the need to improve meaningful social activities and planned new paperwork and possibly an activity coordinator. Some areas also needed decorating.
“Improvements had been identified as required by the provider in relation to people's social care needs.” from the report
- 01What guidance is now in place for every medicine prescribed to be given as needed?
- 02How do you record which decisions a relative with lasting power of attorney can make?
- 03What activities are now available for people who may not be able to join group activities?
- 04Has the planned activity coordinator or new social-care recording system been introduced?
- 05Which areas of the home needed decorating, and have those works been completed?
This was a comprehensive inspection covering all five areas; it also checked that the safety action from the November 2015 inspection had been completed. This explanation was written from the published report of 1 June 2017 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 Southgarth Care Home
3 rated inspections over 4 years: the service has held its Good rating throughout.
- January 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 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.
- September 2011
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 6 April 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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