Southview Lodge Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. They listened to concerns about safety and investigated safety events, but these were not always reported appropriately.

The registered manager did not always ensure incidents were shared with the Care Quality Commission, to ensure duty of candour was followed and safety events were appropriately investigated. There had been several incidents resulting in harm, but the required statutory notifications had not been submitted.

However, lessons were learnt to identify and embed good practice. Records relating to incidents were robust, clearly detailing actions taken and lessons learnt. Staff could explain how they would respond to incidents and accidents, and confirmed details were discussed in handover meetings.

Following feedback, the registered manager took action to submit the appropriate notifications retrospectively.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The provider had systems and processes in place, to protect people from abuse. Concerns were recorded, and the service had introduced a safeguarding log since our last inspection.

People told us they felt safe from abuse or neglect. A person told us, “I feel safe. It is calm and comfortable here and there is a good atmosphere. If I had a concern, I would speak to any of the staff.” Training and detailed policies supported staff member’s understanding of safeguarding and human rights.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive.

Whilst we saw no evidence of impact to people, staff did not always ensure information about risk was robust, so we could not be assured care always met people’s needs safely. For example, several people were at risk of pressure injuries but information about the frequency of repositioning was not always consistent. An analysis of records indicated people did not always receive support to reposition within the timeframes specified in their care plans.

However, when people communicated their needs, emotions or distress, staff could manage this in a positive way that protected people’s rights and dignity. Care plans prompted staff to respond in an empathetic and person-centred manner, entering people’s reality and attempting to reorientate those living with dementia, reducing their anxiety and distress.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology were safe to support the delivery of safe care.

The provider did not have effective arrangements to monitor the safety and the upkeep of the premises. The lock to the basement door was found to be broken, leaving the basement stairs and electrical wiring accessible to people using the service. Some bedroom doors did not fit flush to their casing, rendering them ineffective in the event of a fire. Checks had been completed but had not identified these issues or mitigated associated risks.

However, improvements had been made to several other environmental checks and the safety of the environment since our last inspection.

Following feedback, the provider took immediate action to fix the basement door and implement more robust checks to fire doors.

The provider made sure staff were safely recruited, qualified, skilled and experienced, and received effective support, supervision and development.

The provider now had safe recruitment and induction practices to make sure all staff were suitably experienced, competent and able to carry out their role. A staff file audit had been introduced since our last inspection, to ensure staff had the appropriate checks or risk assessments in place.

Staff received a thorough induction and a robust package of training. A staff member told us, “Yes, it was a good induction. We have a good level of training. Anything we are unsure of [the registered manager] will put face to face training in place.”

The provider used a dependency tool to work out the number of staff required on each shift, and staff we spoke to did not raise any concerns with staffing levels or their workloads. However, we received mixed feedback from people and relatives about staffing levels. One person said, “I think there are enough staff. On occasions I need them, and they come to me quickly.” But a relative added, “I don’t feel there are always enough staff. Sometimes there are plenty and sometimes very few.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider ensured people were protected as much as possible for the risk of infection, by keeping the premises clean and hygienic. We observed there to be good standards of cleanliness throughout the service, and housekeeping staff were available to support the team. One person told us, “I can’t fault the cleanliness. The ladies who clean work very hard.” A relative added, “Everything is spotless.”

Staff understood the importance of food safety, ensuring the kitchen was kept clean and food hygiene standards were adhered to.

The provider had improved systems and processes to prevent the risk of legionella since our last inspection, with regular flushes to little used outlets now in place.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider’s medicines policies and procedures followed current legislation and best practice; and medicines were recorded, stored and disposed of safely, including controlled drugs. An electronic system had been introduced, which alerted the registered manager to any missed medicines; and used barcodes to ensure the correct medicines were administered to people, minimising errors.

Further improvements to the management and oversight of medicines had also been introduced since our last inspection. For example, fridge and room temperature checks, staff competencies and records for topical creams.