CQC report explained · a residential care home
What the CQC found at Southside
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, good risk management and safe medicines administration. Four safeguarding incidents had not always been reported correctly, although this was put right during the inspection.
- Effective?
- Good
- People's needs were assessed and reviewed, staff received induction and training, and people had suitable food, healthcare support and living spaces. Some staff felt online training needed more practical, face-to-face support.
- Caring?
- Good
- People and relatives described staff as kind and respectful. People were involved in care planning and supported to make choices and remain as independent as they wished.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People were supported with communication, activities, relationships, religious needs, complaints and end-of-life wishes.
- Well-led?
- Requires improvement
- The management team had a positive culture but quality systems had not always found problems. There was not always a manager on site, the home exceeded its registered number, four incidents were not notified as required, and medicines checks missed loose tablets.
What inspectors found, October 2023
Rated Good overall, but inspectors found the home’s leadership and quality checks still need improvement.
Inspectors visited on 22, 23 and 29 August 2023. The first visit was unannounced and two further visits were announced. They spoke with people, relatives, staff and managers, observed care, and reviewed care records, medicines records, recruitment files and quality checks.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found people were protected from avoidable harm, supported by trained staff, treated kindly and involved in their care. The home was clean, medicines were generally managed safely, and people had access to health professionals, activities and personalised support.
Well-led was rated Requires Improvement, as at the previous inspection. The home had one more person living there than its registered limit. Four incidents had not been reported to the relevant organisations, medicines checks had missed loose tablets, and a manager was not always on site. The report says there was no immediate or serious risk of harm from the extra person, and the registration issue was being resolved.
People felt safe
People and relatives said they felt safe in the home. Staff understood how to recognise and report abuse and how to manage risks linked to people's health conditions.
“People and their relatives told us the care and support received from staff meant there was confidence that Southside was a safe place to live.” from the report
Kind and respectful care
Inspectors found people were treated with kindness, dignity and respect. Staff involved people in decisions and supported their independence.
“People and their relatives told us staff treated them with kindness and respect.” from the report
Personalised support
Care plans included people's physical, emotional and mental health needs, life histories and preferences. People and relatives were involved in developing and reviewing them.
“Care plans were personalised and contained information relating to people's physical, emotional and mental health needs, their life histories and preferences.” from the report
Activities and relationships
People were offered activities inside and outside the home, including trips, gardening, cycling and social events. Relatives were welcome to visit whenever they wanted.
“People were offered the opportunity to join in with a variety of planned activities both in and outside of the home.” from the report
Good healthcare support
Staff worked with health and social care professionals and made appropriate referrals promptly. This included support from mental health, GP and community nursing services.
“We saw that people had access to a variety of health and social care professionals and appropriate referrals were made promptly as required.” from the report
Too many people registered
needs fixingThere was one more person living at the home than its registered limit. The report says there was no immediate or serious risk of harm, and the provider was taking steps to resolve the issue.
“We found the service had exceeded the registered number of people living at the home. There was no immediate or serious risk of harm from this concern.” from the report
Some incidents not reported
needs fixingFour recent incidents had not been reported to the relevant organisations because management oversight during a changeover was not robust. The report says none caused harm and the issue was corrected promptly.
“There had been 4 recent incidents that had not been notified to the relevant organisations.” from the report
Medicines checks missed loose tablets
needs fixingQuality checks did not identify loose tablets stored in the medicines cabinet that should have been destroyed. They were removed on the first day of the inspection.
“Processes to monitor and check the storage of medication had not identified loose tablets being stored in the medication cabinet that should otherwise have been destroyed.” from the report
Quality systems need strengthening
needs fixingThe provider's quality checks were regular, but they had not always identified areas needing improvement. This was why Well-led remained Requires Improvement.
“The provider's quality assurance processes required some additional improvements as they had not always been effective in identifying areas for development.” from the report
- 01Has the home's registration now been changed to allow 13 people, and what safeguards are in place while this is being resolved?
- 02What changes have been made to ensure all safeguarding and other incidents are reported to the correct organisations on time?
- 03How are medicines now checked to make sure loose or unwanted tablets are removed and destroyed safely?
- 04Who is responsible for the home when the registered manager or deputy manager is not on site?
- 05What practical or face-to-face training is now available for staff who found online training difficult?
The inspection was prompted by concerns about the number of people living at the home and also covered all five key questions and infection prevention and control. This explanation was written from the published report of 21 October 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 2018
Southside was rated Good overall; inspectors found kind, safe and personalised care, but the home needed to improve its quality checks.
Inspectors visited without warning on 5 and 6 December 2017. They spoke with people, relatives, staff and managers. They observed care and looked at care plans, medicines, recruitment, complaints and quality records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough safely recruited staff, medicines given as prescribed, suitable food and healthcare support, respectful care, and activities suited to people's individual needs.
The Well-led rating was Requires Improvement. Most checks were effective, but care plan audits had not been completed since June 2016 and infection control audits since July 2016. Inspectors said this had not affected people, because care plans were current and regular infection control checks were taking place.
Safe staffing and recruitment
Inspectors found enough staff to support people safely. Recruitment checks, including identity, references and DBS checks, were completed before staff started.
“There were sufficient numbers of staff in place to keep people safe.” from the report
Kind and respectful care
Staff were seen treating people with kindness and supporting their privacy, dignity and independence.
“We saw that staff were attentive and had a kind and caring approach towards people and spoke to them affectionately.” from the report
Personalised support
Care plans reflected people's preferences and needs. Activities, sounds, food and surroundings were adapted to individual people.
“We saw that care plans were person centred and showed staff how people preferred to be supported, so that they could receive care that was responsive to their individual needs.” from the report
Food and healthcare
People had a choice of food, drinks and snacks, with support for dietary needs. Staff involved healthcare professionals when needed.
“There was a good selection of food available and people's dietary needs were supported throughout the day.” from the report
Inspectors raised no specific concerns in this report.
- 01When were the care plan audits restarted, and how often are they now completed?
- 02When were the infection control audits restarted, and what did the most recent audit find?
- 03How do you check that care plans remain accurate and reflect each person's changing needs?
- 04How are staffing levels assessed for the 12 people living at the home?
- 05How are personalised activities and end of life wishes recorded and reviewed?
This was an unannounced inspection of the overall service, including all five CQC question areas; feedback from people living at the home was limited. This explanation was written from the published report of 21 February 2018 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 Southside
3 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 21 October 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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