CQC report explained · a nursing home
What the CQC found at Southwoods Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found medicines were not always administered safely or recorded correctly. They also found some missing guidance for topical and as-needed medicines, although there was no evidence that anyone had been harmed.
- Effective?
- Good
- People's needs and choices were assessed, staff had appropriate training and supervision, and people received support with food, drink and healthcare.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward, but that rating is not stated in this report.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward, but that rating is not stated in this report.
- Well-led?
- Requires improvement
- Management systems and reporting had improved, but they failed to identify the concerns about medicine administration. Inspectors recommended improving medicines audits and governance systems.
What inspectors found, August 2023
Southwoods Nursing Home is Rated Requires Improvement; inspectors found good effective care, but medicines were not always managed safely and oversight missed these problems.
This was an unannounced focused inspection. Inspectors visited on 15 and 21 June 2023. They reviewed three care records and medicine records, spoke with one person, six relatives and staff, and gathered information from professionals and the provider.
The home was rated Requires Improvement overall. Safe and Well-led were both Requires Improvement. Effective improved from Requires Improvement to Good. Inspectors found that medicines were not always administered safely and that records and stock checks were not always correct.
There were also positive findings. People had detailed care plans, enough staff, appropriate training, support with food and drink, access to health professionals and involvement in decisions. The home had improved its management systems, but these systems had not found the medicine problems.
The home has been rated Requires Improvement for the last five inspections. The CQC will ask for an action plan and monitor progress with the provider and local authority.
Detailed care planning
Care plans were person-centred and gave staff useful information about how people wanted to be supported. People and relatives were involved where appropriate.
“Care plans were person-centred and contained a good level of detail to ensure staff were guided accurately to deliver care as the person wished.” from the report
Staff training and support
Inspectors found a comprehensive training plan, competency checks, induction, supervision and appraisals.
“A comprehensive training plan was in place. The registered manager monitored completion of training and conducted competency checks.” from the report
Food and drink support
People could choose what to eat and drink and were supported without being rushed. Food was provided at the correct temperature and for people's dietary needs.
“People were able to choose what they wanted to eat and drink and had good access to food and drinks throughout the day.” from the report
Staffing and risk management
Inspectors found enough staff and appropriate recruitment checks. Risks were assessed and reviewed, while people were supported to keep their independence.
“There were sufficient staff to support people's needs.” from the report
Medicine safety
seriousMedicine records were not always completed correctly. Stock discrepancies were not always investigated, and some medicines lacked the guidance needed for safe and consistent administration.
“Medicines were not always administered safely because medicine records were not always completed correctly.” from the report
Management missed medicine problems
seriousThe home had developed stronger governance systems, but these checks did not identify the medicine concerns found by inspectors.
“The management systems had failed to identify the concerns we found in medicine administration.” from the report
Infection control actions unfinished
needs fixingThe home was managing infection risks, but improvements recommended in a recent infection control audit had not yet all been completed.
“We noted a recent IPC audit had recommended improvements to the environment and work was underway to complete required actions.” from the report
- 01What has been changed to make sure every medicine administration record is completed correctly?
- 02How are discrepancies in medicine stock counts now escalated and investigated?
- 03What written guidance is available for topical medicines and medicines prescribed to be given as needed?
- 04How will managers check that medicine audits identify problems promptly?
- 05When will the remaining environmental actions from the infection control audit be completed?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and the overall rating used ratings carried forward from the previous inspection. This explanation was written from the published report of 10 August 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, May 2022
Rated Requires Improvement; inspectors found kind, responsive care, but weaknesses in governance, staff training and medicines checks remained.
This was an unannounced inspection on 14 and 19 April 2022. One inspector and an Expert by Experience spoke with people, reviewed four care records and checked management records, audits and policies. They also spoke by telephone with five staff members and 15 relatives.
The home cared for 26 older people and could support up to 38. Inspectors found that staff knew people well and treated them with kindness. People's care, food, activities and access to health professionals were generally good, but care plans did not always record people's preferences and life histories.
The main weaknesses were outdated policies, incomplete staff records, gaps in training and supervision, and checks that did not always identify problems. Medicines records were completed correctly, but not all staff had their medicines competency checked. The home remained in breach of Regulation 17 on good governance.
The overall rating stayed at Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement, while Caring and Responsive were rated Good. The provider had started improvements, but inspectors said these needed more time to show a lasting effect.
Kind and respectful staff
Inspectors found positive relationships between people and staff. People were treated with dignity and respect.
“Staff always treated people with kindness and respect.” from the report
Enough staff on duty
The home had enough staff to meet people's individual needs and keep them safe. Staffing levels were planned using a dependency tool.
“There were enough staff on duty to meet people's individual needs and maintain their safety.” from the report
Food and health support
People received a varied diet, including support for allergies and food textures. Staff worked with health professionals and made timely referrals.
“People's eating and drinking needs were met by a varied and nutritionally balanced diet.” from the report
Infection control
Inspectors were assured about the home's infection prevention arrangements, including PPE, cleaning, testing and outbreak management.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Weak management checks
seriousAudits did not identify problems with records, staff training and staff files. The provider remained in breach of Regulation 17, as at the previous inspection.
“The providers audit systems did not identify issues found during this inspection regarding records; gaps in staff training and files.” from the report
Medicines oversight
seriousMedicines records had no gaps, but the medicines policy was outdated and not all staff who gave medicines had their competency checked.
“Not all staff who administered medicines had their competency checked by the manager.” from the report
Staff training and supervision
needs fixingSome training had lapsed, including training linked to people's individual needs. Not all staff received supervision during the change of managers.
“Staff training was not up to date some areas that needed refreshing had lapsed.” from the report
Care plans lacked personal detail
needs fixingStaff knew people well, but this knowledge was not always recorded in care plans. Plans did not always include preferences and life histories.
“The support people received was individual to their needs and staff knew people well, but their care plans didn't reflect this.” from the report
Communication with relatives
needs fixingSome relatives said communication from the home needed improvement. There were no regular systems for sharing information or collecting people's and relatives' views.
“There were no regular systems in place for communicating with relatives regarding peoples care and support.” from the report
- 01Have all staff who administer medicines now had their competency checked, and when was the medicines policy last updated?
- 02What training is now complete for diabetes, epilepsy, learning disability and DoLS?
- 03How are falls, accidents and incidents now analysed so that lessons are acted on?
- 04How are care plans being updated to include each person's preferences, life history and personal choices?
- 05What regular arrangements are now in place to communicate with relatives and collect their views?
This was an unannounced inspection covering all five key questions and infection prevention and control; Caring was rated for the first time with this provider, while Safe, Effective, Responsive and Well-led had been rated at the previous inspection. This explanation was written from the published report of 27 May 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 Southwoods Nursing Home
8 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- August 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- January 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 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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