CQC report explained · a nursing home
What the CQC found at Southwell Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, safeguarding systems were in place, medicines were given safely, infection controls were effective and there were enough safely recruited staff.
- 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. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found an open, inclusive and person-centred culture. Managers used quality checks effectively, involved people and relatives, and worked with other professionals.
What inspectors found, July 2023
Rated Good; inspectors found safe, kind care and effective management after concerns about medicines and care risks.
This was an unannounced focused inspection on 31 May and 1 June 2023. Inspectors reviewed Safe and Well-led only because concerns had been raised about medicines and people's care and support risks. They spoke with people, relatives, staff and healthcare professionals, and checked care, medicine, recruitment, incident and management records.
The inspectors found people were protected from abuse and avoidable harm. Risks were assessed and reviewed, medicines were given safely, infection controls were in place, and there were enough safely recruited staff. People and relatives described staff as kind and knowledgeable.
The home was also found to be well-led. Managers used audits and investigations to identify and address problems, involved people and relatives, and worked with health and social care professionals. The overall rating remained Good, but the other three key questions were not inspected during this visit and carried over from the previous inspection.
Safety systems
Safeguarding, risk assessment and incident review systems were in place. Inspectors found that concerns were investigated and lessons were shared.
“Systems in place protected people from the risk of abuse and neglect.” from the report
Kind and familiar staff
People and relatives said staff were kind and knew people well. Inspectors also found there were enough staff to meet people's needs.
“People and their relatives told us they were supported by kind staff who knew them well.” from the report
Safe medicines support
Medicine records included important safety information and instructions for medicines given when needed. Staff had medicines training and competency checks.
“People received their prescribed medicines safely.” from the report
Open management
People, relatives and staff said managers were approachable and supportive. Regular meetings gave people a chance to discuss food, care, maintenance and the home.
“The registered manager, deputy manager and all staff worked hard to ensure the culture was open, inclusive, and person-centred.” from the report
Quality monitoring
Audits and reviews were used to find areas needing improvement. Incidents were reported and reviewed in a timely way.
“Quality assurance processes were used to monitor the service effectively which reduced the risk of avoidable harm.” from the report
Inspectors raised no specific concerns in this report.
- 01What extra monitoring is now in place for prescribed creams, following the issue identified in the medicine audit?
- 02How will you assess and review risks for my relative as their needs change?
- 03How are relatives told about accidents, incidents or safeguarding concerns involving their family member?
- 04How often are care and support plans audited, and how are any shortfalls corrected?
- 05How can residents and relatives raise concerns or suggest changes through meetings or directly with managers?
This was an unannounced focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were not inspected and carried over from the previous inspection. This explanation was written from the published report of 14 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, March 2022
Inspected but not rated; inspectors found strong COVID-19 infection controls, but one new admission lacked a recorded risk assessment and day-one test evidence.
This was an unannounced, targeted inspection on 4 February 2022. It looked at infection prevention and control during the COVID-19 pandemic, and asked about staffing pressures.
Inspectors found robust visiting arrangements, regular testing, clean premises and good use of protective equipment. They were assured that the home was managing infection risks and meeting vaccination requirements for relevant staff and visiting professionals.
There was one shortfall. A recently admitted person did not have a recorded risk assessment, and there was no recorded evidence of a COVID-19 test on the day of admission. The service was inspected but not rated, so this report does not give an overall quality rating.
Careful visiting arrangements
Visits were allowed, but they were staggered and supported by testing, temperature checks and cleaning before and after visits.
“There were robust processes for ensuring visits were staggered to allow cleaning and disinfection of people's bedrooms before and after each visit.” from the report
Clean premises
Inspectors found the premises clean, with extra cleaning of frequently touched surfaces.
“The premises were clean. Staff completed enhanced cleaning of frequently touched surfaces to reduce the risk of the spread of infection.” from the report
Protective equipment
There was enough protective equipment, and staff were seen using, changing and disposing of it correctly.
“Staff were observed wearing, regularly changing and disposing of personal protective equipment (PPE) correctly to reduce the risk of infection.” from the report
Regular testing
The home had a regular COVID-19 testing programme for people living there, staff and visitors.
“A programme of regular COVID-19 testing for people in the service, staff, and visitors had been implemented.” from the report
Admission records
needs fixingOne recently admitted person did not have a recorded risk assessment. There was also no recorded evidence of a COVID-19 test on the day of admission, as government guidance required at that time.
“However, one person who was recently admitted into the service did not have a risk assessment and there was no recorded evidence of a COVID-19 test on the day of admission (day 0) in line with the government guidance.” from the report
- 01How do you make sure every new resident has a recorded infection risk assessment before or on admission?
- 02How do you record the COVID-19 test taken on the day of admission?
- 03What infection control measures are currently used for visits?
- 04How often are residents, staff and visitors tested now?
- 05How do you manage staffing pressures if staff are absent because of COVID-19?
This was an unannounced targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated. This explanation was written from the published report of 1 March 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 Southwell Court Care Home
3 rated inspections over 7 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2022Inspected but not ratedSafe: Inspected but not rated
- March 2021Inspected but not ratedSafe: Inspected but not rated
- November 2020Inspected but not ratedSafe: Inspected but not rated
- July 2019Goodstayed GoodSafe: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- January 2014
Registered with the Care Quality Commission on 8 January 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.
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