CQC report explained · a residential care home
What the CQC found at Southport Rest Home Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and care plans were not always sufficient, especially for people staying for respite care. Inspectors found safe medicines practice, safeguarding systems and enough staff during the inspection.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Inspectors did observe caring and patient support, and people and relatives spoke positively about the care.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Audits and checks were missing or ineffective. The provider and manager had not identified some shortfalls in risk assessments, care plans, recruitment records and fire safety monitoring.
What inspectors found, July 2023
Requires Improvement; inspectors found caring staff and safe medicines practice, but weaknesses in risk records, fire safety checks and management systems.
This was an unannounced focused inspection on 17 and 24 May 2023. Inspectors looked only at Safe and Well-led, after concerns about infection control and fire safety. They spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home was rated Requires Improvement for Safe and Well-led. Risk assessments and care plans were not always up to date, especially for people staying for respite care. Checks of the building and care quality were not effective enough, and some records did not show what action had been taken.
Inspectors also found enough staff on the inspection days, kind and patient care, safe medicines practice, infection control systems and appropriate safeguarding arrangements. The overall rating fell from Good at the previous inspection in 2019 because the two inspected areas had worsened.
The provider breached Regulation 17 on good governance. CQC requested an action plan and said it would monitor progress with the provider and local authority.
Kind, patient care
People were not rushed and staff spent time talking with them. People and relatives said they were happy with the care and felt staff knew them well.
“People were comfortable in the presence of staff and positive relationships had developed.” from the report
Enough staff
Inspectors saw staff available and attentive during both inspection days. Most people said there were enough staff to meet their needs.
“We observed staff were attentive and available to meet people's needs on each day of our inspection” from the report
Medicines managed safely
Medicines were stored securely, given by trained staff and recorded in line with best practice.
“Medicines were safely managed. Records of administration were maintained and in line with best practice.” from the report
Infection control
The home had systems to prevent and control infection, and had appointed an infection control champion. People said the home and bedrooms were clean.
“Systems were in place to prevent and control the risks of infection.” from the report
Incomplete risk information
seriousSome risk assessments and care plans did not fully reflect people's current needs. This was particularly an issue for a person staying for respite care, where important health information was limited.
“Improvements were needed to ensure all people who use the service had appropriate risk assessments and care plans which reflected their current care needs.” from the report
Weak management checks
seriousAudits and regular checks were absent or ineffective. They had not identified problems with care records, recruitment records or fire safety, and did not show clearly what had been done to fix them.
“Systems were either not in place or robust enough to assess, monitor and improve the quality and safety of the service” from the report
Fire safety concerns
seriousBefore the inspection, the provider had received a Fire Enforcement Notice because of safety issues. CQC later received confirmation that sufficient action had been taken, but the earlier checks had failed to identify the significant concerns.
“Prior to our inspection, the provider had been issued with a Fire Enforcement Notice due to safety issues identified at the service.” from the report
Staffing review process
needs fixingStaffing levels were safe during the inspection, but the manager did not have a formal system to calculate and review staffing based on people's needs.
“However, the registered manager did not have formal systems in place to calculate and review staffing levels based on the needs of people using the service.” from the report
- 01How have you updated risk assessments and care plans, especially for people staying for respite care?
- 02What evidence can you show that the fire safety issues and Fire Enforcement Notice have been fully addressed?
- 03How are audits now checking care records, recruitment records, the environment and the quality of care?
- 04How do you calculate and review staffing levels against the needs of the people living here?
- 05What action plan did you send to CQC, and what improvements have been completed since the inspection?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 12 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, April 2019
Southport Rest Home Limited was rated Good; inspectors found kind, personalised care, with medicines records needing close attention.
This was an unannounced, one-day inspection on 8 April 2019. Inspectors spoke with six people living at the home, two relatives, staff and managers. They observed care and checked care records, medicines records, meetings and audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were safe, their needs were understood, and care was kind, respectful and personalised. The home was clean, food choices were good, and staff worked with health professionals.
There had been a significant number of recorded medicines errors, mainly involving stock counts and related records. The home had increased its medicines audits. Inspectors also noted high staff turnover, although people said this had not affected their care.
The previous rating was also Good, in a report published on 19 July 2018. The report says legal requirements were met and does not identify any breaches.
Safe, knowledgeable care
Staff knew people well and understood how to manage their risks. Inspectors found risk assessments were detailed and regularly reviewed.
“People were cared for by staff who knew them well, understood their needs and provided effective care to keep them safe.” from the report
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors saw staff protect people's dignity, privacy and independence.
“Staff treated people with kindness and respect and supported their dignity in a sensitive manner.” from the report
Personalised care
Care records included important information about people's histories, families and preferences. Staff used this information to tailor care and activities.
“Care records captured important information regarding people's histories, families and preferences.” from the report
Positive management
Managers used audits and other information to monitor quality. They responded to medicines concerns by increasing audit frequency and refreshing training.
“The registered manager placed continuous learning and improvement at the heart of their practice.” from the report
Medicines recording errors
needs fixingInspectors found a significant number of medicines errors over the previous year. Most related to stock counts and associated records and had not stopped people receiving medicines, but the home had increased its checks.
“There had been a significant number of medicines errors recorded during the previous 12 months.” from the report
High staff turnover
needs fixingThe home had experienced high staff turnover during the previous year. People told inspectors this had not affected the quality of their care, but families should ask about current staffing and continuity.
“The home had experienced a high level of staff turnover during the previous 12 months.” from the report
- 01What changes were made to medicines audits and stock control after the errors identified in this report?
- 02How has staff turnover changed since the inspection, and how do you maintain continuity for residents?
- 03Has the accredited specialist training discussed during the inspection been completed, and how is it used in care?
- 04What progress has been made with the planned bathing facilities for people with mobility difficulties?
- 05What progress has been made with the planned signage for people living with dementia?
This was an unannounced, one-day inspection covering all five CQC questions, including the premises and care provided. This explanation was written from the published report of 24 April 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.
Every inspection of Southport Rest Home Limited
8 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2019Goodstayed GoodSafe: GoodWell-led: Good
- July 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2016Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2015Inspected but not ratedSafe: Requires improvement
- February 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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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