Southernwood House

Updated 26 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of one inspector.

Service and service type

Southernwood House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Southernwood House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager for the service, however, they were taking a leave of absence and an interim manager was in place.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people living at the home. We also spoke with the manager, the deputy manager, a carer, the cook and a housekeeper. We spent time observing care to see what it was like to live in the home.

We reviewed a range of records. This included 4 people’s care records and multiple medication records. We also looked at a variety of records relating to the management of the service, including policies and procedures.

Updated 26 July 2023

About the service

Southernwood House is a residential care home providing personal care to up to 28 people. It is in an adapted building. The service provides support to adults of all ages, some of whom may be living with a physical disability or dementia. At the time of our inspection there were 19 people using the service.

Southernwood House also provides care to people in their own home. We did not review this part of the care provided as only two people were using the service at the time of the inspection and their care was in the process of being transferred to a new service provider.

People’s experience of using this service and what we found

Medicines were not always safely managed and audits in place to monitor the safety of medicines were not effective in keeping people safe.

Other audits in the home identified areas for improvement and the manager took action to make changes and enhance the quality of care provided. The manager gathered the views of people using the service and staff to identify areas for improvement.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There were enough staff in place to meet people’s needs and staff had received the training needed to provide safe care. Staff had been safely recruited to ensure they were safe to work with people living at the home.

Risks to people receiving care had been identified and care was planned to keep people safe. The home was clean, and staff wore PPE correctly to reduce the risk of infection.

Where concerns were raised the manager worked with the local authority and healthcare professionals to ensure people were safe and well.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 13 August 2022).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

We made a recommendation at the last inspection regarding audits. We found medicines audits were still ineffective at supporting the safe management of medicines.

The last rating for this service was requires improvement (published 13 August 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We received concerns in relation to risk management, medicines management and infection control. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has remained requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Southernwood House on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to the safe management of medicines and the auditing of medicines which had not picked up ongoing and recurrent issues at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.