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Archived: Reside at Southwood Inadequate

We are carrying out a review of quality at Reside at Southwood. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 14 July 2018

This comprehensive inspection took place on 1, 4, 8 and 11 May 2018. The first day of the inspection was unannounced. We gave the provider short notice of our visits on the other days so that the manager and staff would be available to speak with us, and appropriate records would be available.

Reside at Southwood is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to accommodate a maximum of 38 people who require support with personal care. There were 24 people living in the home at the start of our inspection.

The service comprises three individual houses which have been linked together to form one building. Accommodation is provided in individual bedrooms on the ground, first and second floors. Some rooms have ensuite facilities. There are two lounges and a dining room on the ground floor. The home specialises in providing care to people living with dementia.

The service was led by a new manager who was not registered with the commission but confirmed that they had submitted an application to become registered. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This inspection was brought forward from the planned date because we received information of concern and safeguarding alerts from the local authority. At our last inspection in January 2018, we found shortfalls in a number of areas and the service was rated Inadequate and placed in special measures. At that time we found breaches of the regulations relating to the way people received care and treatment, that people's consent was not always properly obtained and people were not always treated with dignity and respect, the management and administration of medicines, the management of risks to people, premises and equipment that was not safe to use, the recruitment, training and supervision of staff, the service did not act in accordance with the Mental Capacity Act 2005, quality monitoring systems were not effective and record keeping required improvement.

At the last inspection there were nine breaches of the regulations. At this inspection action had been taken to comply with one of the regulations but the other eight breaches of regulations were repeated.

The feedback we received from people and their relatives and visitors was that staff were kind and most people were happy living at Reside at Southwood. We observed that not all of the staff made meaningful connections with people and therefore not everyone received person centred care. This was because many of the staff focussed on completing a task and then moving to the next task.

At the last inspection, systems and procedures to ensure people were safe in the event of an emergency were not effective. At this inspection we found that work was underway to ensure this was addressed but not all staff had received training in the action to take in the event of an emergency. Also, they had not taken part in a fire drill to practice their learning.

We raised concerns about the number of staff on duty at night at the last inspection and at this inspection found that this had been addressed. However, actions to ensure that staff had the necessary skills, training and competence to care for people and meet their needs had not been completed. Failure to complete thorough moving and handling training for staff had continued to place people and staff at continued risk of injury.

We again found that systems to manage the administration of medicines were not robust and meant that people may not always be

Inspection areas



Updated 14 July 2018

The service was not safe and people had continued to be put at risk.

Systems for the management of medicines were unsafe and did not fully protect people.

Care was not always planned and delivered in a way which protected people from the risk of harm.



Updated 14 July 2018

The service was not effective and people had continued to receive ineffective support and care.

Some people had lost weight and may not always have received appropriate food and drink or been supported to eat and drink enough to meet their needs.

Staff had not always received the training, supervision and support they needed.

People's rights were not always protected because the service was not acting in accordance with the Mental Capacity Act 2005.



Updated 14 July 2018

The service was not caring.

Action had not been taken to ensure that people�s human rights to privacy, dignity and respect were upheld.

Staff did not always support people in a person centred manner and their privacy and dignity was not always promoted and protected.



Updated 14 July 2018

The service was not responsive.

People had continued to be put at risk of receiving unsafe care because their care plans were not up to date and detailed. Changes in needs were not always re-assessed and planned for and contradictory instructions were not identified and questioned.

People did not always receive appropriate support to meet their personal care needs.

The service had a complaints policy and complaints were responded to appropriately.



Updated 14 July 2018

The service was not well led.

The provider had continued to fail in meeting their responsibilities to manage the service under the Health and Social Care Act 2008. There were multiple repeated breaches of regulations.

Again, action had not been taken to assess, monitor and mitigate the risks to people living at the home.

Again, quality monitoring systems were ineffective and record keeping required improvement.