Archived: Southlands Nursing Home

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained to requires improvement. This meant people did not always feel well-supported, cared for or treated with dignity and respect.

The service was in breach of legal regulation in relation to person-centred care.

This service scored 40 (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 treat people with kindness, empathy and compassion, or respect their privacy and dignity.

During our visits staff were all approachable and friendly and whilst we made observations of staff practices that were kind and compassionate, some of the interactions we saw were task focused and lacked a person-centred approach. Staff appeared rushed and there was not always a consistent staff presence in areas where people were. For example, a person on the first floor was heard shouting and banging their cup on the table at 10.45am, however there was no visible staff. On reviewing the person’s record, they did not receive assistance until 11.39. One person told us, “Poor [person], you get fed up with hearing it. It gets monotonous. If you keep the TV loud you can drown out the sound. You can’t do much about it”.

Feedback from people and relatives was mixed, comments included, “You can’t find anyone, ever. It’s bedlam sometimes. There’s not always someone in the lounge” and “They [staff] rush from job to job. They [staff] haven’t time to stop and chat. They’re so devoted to people, they don’t take time off, even if they’re ill”.

Further feedback from people included, “Some [staff] are kind. Some [staff] are very friendly, but some [staff] can be snappy, but then [they’ve] got a lot of things to do. I asked one of them [staff] to help me, I said when you’ve got the time. [Staff member] said, ‘I’ve only got one pair of hands.’ I said sorry, I didn’t know [staff] been asked to do something else. I only asked [staff] to help when [they] got a minute” and “Yes, most of them [staff] are. There may be the odd one who says they have to go and see to someone else and then they don’t come back”.

The provider did not treat people as individuals or make sure people’s care, support and treatment met people’s needs and preferences. The provider did not take account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.

Care plans did not contain sufficient guidance for staff to manage specific conditions and enable them to provide consistent support to people. For example, people living with dementia had a lack of detailed information in their care plans to support staff to understand how their dementia impacted them as a person and how to support them through their dementia journey.

The providers training records showed shortfalls in dementia training. For example, out of 29 staff including nurses, carers and activities coordinators there were 25 staff who did not have training in responding to changes in people’s behaviour and 23 staff who did not have de-escalation strategies for people who are living with dementia.

We observed a group activity in the lounge on 19 August 2025. A game of bingo had been arranged, 12 people were present as well as several relatives with staff assisting, people appeared to enjoy this and there was a good deal of laughter and joking. People we spoke with told us they liked bingo. However, we did not observe people who spent time in bed or in their rooms being supported to engage in meaningful activities when they were unable to join in and appeared to have limited interaction.

Feedback in relation to activities provision for people who spent time in their room included, “There’s nothing like that. I would go mad if I didn’t have the TV. I’ve got DVDs and I play games on my phone. I sleep more because I’m bored”, “They [staff] don’t come up”, “They don’t come in here for activities, not at all” and “It’s all right. There’s hardly any staff. There’s no activities in the week. It’s very boring”.

We reviewed records of activity provision for the period between 1 June to 18 August 2025 for 3 people who spent time in bed or in their rooms. These demonstrated they had less than 10 hours each of social activity over this 79 day period. There appeared to be limited meaningful interaction and only task-based activities such as hairbrush, shave and watching TV. We could not be assured that people received daily stimulation which placed them at risk of social isolation. In addition, we found a lack of support for people related to their religious, spiritual and cultural needs.

The provider did not promote people’s independence, so people did not know their rights and have choice and control over their own care, treatment and wellbeing.

We were not assured that baths, showers and oral hygiene were regularly offered or provided to people to maintain their basic hygiene needs and ensure they were supported in a dignified way.

We reviewed the hygiene records for a 110-day period between 1 May to 18 August 2025, records showed that baths and showers were not an option for some people and bed baths or washes were the recorded choices on the system. For example, a person’s care plan described them as liking a shower once a week however, the personal care charts demonstrated that only 2 showers and 2 baths had been given during this period. Another person’s care plan stated they preferred a shower once a week however, no showers had been given during this period, and their personal care was provided by bed baths and washes only.

We asked for feedback from people, and relatives where appropriate, about baths, showers and oral care as we were concerned people were experiencing a lack of choice and control over their personal care needs. Comments were mixed and included, “You have to ask for them [staff]. You have to give them [staff] notice. They [staff] wash you every day though”, “I have a bed bath every day in the mornings. They [staff] offer me a bath, but I don’t want one, I don’t trust the sling”, “We say if [loved ones] a bit ‘whiffy’, they [staff] come straight away”, “[Loved one] gets sores in their mouth. I looked inside their mouth and their teeth [dentures] were disgusting. They needed scrubbing. They’re not always clean” and “[Loved one] has 2 showers a week, Wednesday and Sunday”.

The providers processes to ensure that people’s preferences in relation to when they would like to get up and go to bed were not effective, and care plans did not demonstrate that people’s preferences had been considered or documented. On day 1 of our visit, we arrived at the service at 7am. We observed 4 people in the dining room sat at tables and all of them were asleep and a radio was playing quite loudly. Staff told us they started to get people up from 6am then further stated, “Shame we got to get them up, but it helps the day staff”. At 7.30am one person was clearly expressing they were hungry and wanting their breakfast. Staff told us the people in the dining room had received a hot drink; however they had not received their breakfast and this was done when the chef came in around 8am.

Where people’s records demonstrated their nutritional likes and dislikes these were not always respected. For example, a person’s records documented a dislike of fish, however, the meal charts recorded fish had been given on 4 days out of 29. Another person’s records stated they dislike potatoes, however the meal charts recorded that meals containing potatoes had been given.

We observed lunch which was served to 10 people in the dining room. People were invited to choose where to sit but because the chairs were cumbersome and the room was small, manovering people to where they wanted to sit took time. After drinks were served, 2 people were served their first course, however, there was then a 20-minute delay in providing more meals. Some people were asked if they wanted a clothes protector, but others were not given a choice.

The provider did not always listen to and understand people’s needs, views and wishes. Staff did not always respond to people’s needs in the moment or act to minimise any discomfort, concern or distress.

During our assessment visits we observed call bells ringing consistently, some were answered promptly by staff, and some bells rang for long periods without being responded to. The management told us the call bell system did not have the facility to download a report in order for them to audit call bell times and responses. This meant there was no management oversight of the timings that staff took to respond to people’s immediate needs.

We asked people and relatives if they had to wait for support and if staff acted quickly if they pushed their buzzer. Feedback included, “They [staff] usually come quickly, usually they [staff] take about 20 minutes. Sometimes they [staff] come very quickly. If you push the emergency button, they [staff] drop everything and come straight away”, “Sometimes it seems they [staff] are always elsewhere. It’s probably because they [staff] have to cover two floors. It depends on what level of care each resident needs” and “Sometimes you have to wait. The other night it was 7.15 and I was wet, and it had gone through. They [staff] said I had to ask the night staff to change my pad for me. They [staff] say it’s not their job. I take medicine and I pee. I’m wet and don’t want to lie in that.”

The provider did not always care about and promote the wellbeing of their staff. They did not always support or enable staff to deliver person-centred care.

The management team told us they celebrated their workforce through the employee of the month initiative where they would award the employee with recognition, a little treat such as, a bottle of wine or chocolate and display their photo on the wall, however, they had not completed this for a couple of months. Staff told us there used to be a reward scheme but not with the manager.

During discussions with the management team it became apparent that the employee scheme had not been used for at least 8 months. Whilst the management team told us that this would be reintroduced, at the time of our inspection this could not be demonstrated.

Following a period of sick leave, one staff member told us that there was a lengthy delay in their return to work interview. Feedback from staff about the management was mixed, some reflected that they felt supported, however staff also reflected that they could raise concerns but that actions were not taken in response.