CQC report explained · a residential care home
What the CQC found at Southway
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Investigations into injuries were not thorough, risk assessments and fire safety arrangements were incomplete, and medicines were not always supported by clear plans. Inspectors also found concerns about staffing oversight and some mental capacity decisions.
- Effective?
- Good
- This key question was not rated in this inspection. The report did note gaps in medicines care planning and the use of the Mental Capacity Act.
- Caring?
- Good
- This key question was not rated in this inspection. Inspectors found that some staff interactions did not consistently respect people's needs or wishes.
- Responsive?
- Good
- This key question was not rated in this inspection. Inspectors found limited dementia-friendly information and examples where staff did not respond appropriately to people's needs.
- Well-led?
- Requires improvement
- Management audits did not identify or correct important shortfalls in care records, medicines, staffing, fire safety, recruitment checks, the Mental Capacity Act and the upkeep of the home.
What inspectors found, September 2022
Southway was rated Requires Improvement; inspectors found risks in safety checks, incident responses, medicines and management oversight.
Inspectors visited the home on 22 June 2022 and carried out inspection activity until 4 July 2022. They spoke with people living there, relatives and staff, and reviewed care records, medicines, recruitment checks, safety documents and management audits.
The home was not always safe. Investigations into injuries were not thorough, risk assessments lacked important details, and fire safety plans and drills needed improvement. There were also problems with medicines information, staffing oversight and some mental capacity decisions.
The home was not always well-led. Managers and the provider had not found or corrected problems through their audits. Inspectors identified breaches of Regulation 12, Safe care and treatment, and Regulation 17, Good governance.
The overall rating fell from Good at the previous inspection, published on 1 February 2020, to Requires Improvement. The CQC asked for an action plan and said it would monitor progress and consider further action if needed.
Positive views from people
People said they were happy living at the home. Relatives also said their family members were safe and welcomed by staff.
“People's relatives were confident their loved ones were safe, and staff had got to know them.” from the report
Daily choices
Staff understood the importance of offering people choices about their care and food.
“Staff did understand the importance of offering people daily choices about their care and food.” from the report
Infection control
Inspectors were assured that the home had arrangements for preventing and managing infections, including safe visiting during COVID-19 symptoms.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Injuries and safeguarding
seriousThe home did not consistently investigate bruises and cuts or consider safeguarding referrals and actions to prevent injuries happening again.
“We found examples of when people had a bruise or cut, which were not effectively investigated.” from the report
Risk assessments and fire safety
seriousRisk assessments did not always explain the risks people faced or tell staff what to do. Fire drills, evacuation plans and the fire risk assessment also needed improvement.
“We found issues with fire drills, evacuation plans, and ensuring there was an up to date fire risk assessment in place.” from the report
Medicines
seriousSome antibiotics did not have care plans or protocols explaining when to use them. Inspectors also found problems with patch administration and medicine records.
“Thirteen people had all been prescribed antibiotics by the GP in case they needed them.” from the report
Staff time and support
needs fixingPeople spent regular periods without staff engagement, and the managers had not checked whether staffing levels allowed enough time for social contact.
“People spent regular periods on their own with no staff engagement.” from the report
Respectful, responsive care
needs fixingInspectors saw examples of staff not responding to a person's request for help and continuing to offer food when another person indicated they wanted this to stop.
“Staff did not respond when one person stated in an animated way, they needed support to use the bathroom.” from the report
Weak management checks
seriousAudits had not identified important problems in care, medicines, staffing, fire safety, recruitment checks, mental capacity work and the condition of the home.
“The manager's and provider's audits had not identified these shortfalls with plans in place to rectify these issues.” from the report
- 01What action has been completed to investigate injuries properly and make safeguarding referrals when needed?
- 02How are risk assessments, fire drills, evacuation plans and the fire risk assessment now kept up to date?
- 03What care plans and professional guidance are now in place for antibiotics and medicines given through patches?
- 04How do you check that there are enough staff to spend time with people and respond to them promptly?
- 05What changes have been made to management audits so that shortfalls are found and corrected?
This inspection rated Safe and Well-led only; the report does not give ratings for Effective, Caring or Responsive in this inspection. This explanation was written from the published report of 1 September 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.
What inspectors found, November 2020
Inspected but not rated; inspectors were assured about infection control, but had some reservations about premises layout and hygiene.
The inspection took place on 2 November 2020 as part of a CQC review of infection prevention and control in care homes during the coronavirus pandemic. It was announced in advance.
Inspectors found good arrangements for visits, social distancing, personal protective equipment, testing, safe admissions and managing outbreaks. They also found the infection prevention and control policy was up to date.
The home had a separate visitors' room, with visits booked for 20-minute periods and cleaning between visits. Staff also had equipment to monitor people's temperature, blood pressure and oxygen levels so that worsening health could be identified early.
The service was inspected but not rated. This means the visit looked at infection control arrangements only and did not give an overall quality rating.
Safer visiting arrangements
The home had a separate visitors' room with external access. Visits were scheduled and the room was cleaned between them.
“A room has been allocated for the exclusive use of visitors which can only be accessed from an external door.” from the report
Support for private calls
Headphones were available to help people hear telephone and video calls and have private conversations.
“The registered manager had also purchased head phones for use by people when making telephone and video calls enhancing their ability to hear and have private conversations.” from the report
Health monitoring
Staff could record and interpret key health observations to help identify when someone's health was deteriorating.
“The provider was participating in the whzan programme which enabled staff to complete observations of temperature, blood pressure and oxygen saturations” from the report
Infection control procedures
Inspectors were assured that the home used PPE safely and had arrangements for testing, safe admissions and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Premises layout and hygiene
needs fixingInspectors were not fully assured that the layout and hygiene practices of the premises promoted safety. The report does not give further detail about the problem.
“We were somewhat assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
- 01What changes have been made to the layout and hygiene practices since inspectors were only somewhat assured about them?
- 02How is the visitors' room cleaned between each 20-minute visit?
- 03How do you make sure PPE is used safely by all staff and visitors?
- 04How are temperature, blood pressure and oxygen levels recorded, and what happens when they suggest someone is becoming unwell?
- 05How are people admitted safely, including those staying for respite care?
This was a focused thematic inspection of infection prevention and control during the coronavirus pandemic; the service was inspected but not rated overall. This explanation was written from the published report of 13 November 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.
Every inspection of Southway
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not rated
- February 2020Goodstayed GoodSafe: GoodWell-led: Good
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Registered with the Care Quality Commission on 7 April 2014.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
88 live-in carers within about an hour of Bedford
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.
Most charge £980 to £1,260 a week. 76 can care for a couple. 12 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“She handled the new situation in front of her with such professionalism and I felt I could trust her 100%.”
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.