Archived: Southlands Nursing 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 remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of 2 legal regulations in relation to safe and effective staffing and care and treatment including safe management of risks, safe management of medicines and infection control.

This service scored 50 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were clear processes and systems in place to help ensure where concerns were identified, these would be investigated and acted on in a timely way. These investigations included the completion of root cause analysis to establish potential causes, themes and trends and mitigation to prevent future incidents.

Feedback received from people and relatives demonstrated the service had taken action to mitigate further occurrences in relation to falls. A relative told us that there loved one had a fall and that the service put measures in place to mitigate the risk such as putting a pressure mat in place. Another relative told us, “They are very, very hyper- vigilant about falls, especially falls from chairs and that’s what [loved one] had. They advised us on what was the best chair for [loved one]”.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People and relatives confirmed they had access to GP services, dentists and chiropodists where required. On review of peoples care records we found evidence that people received additional support as needed from the older persons mental health team and speech and language therapists.

Care files included a hospital pack containing relevant information if a person needed to be admitted to hospital or transferred to another service, this helped to ensure continuity of care.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People were not always protected from neglect and avoidable harm due to the concerns identified within other quality statements of this report such as, involving people to manage risk, medicines and staffing. We were concerned about response times and delays in meeting peoples continence needs. Feedback from people corroborated our concerns with comments such as, “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.” This placed people at risk of avoidable harm.

There were clear processes and systems in place to help ensure that where incidents and accidents were identified, these would be investigated and acted on in a timely way. Referrals had been made to the local safeguarding team and CQC appropriately.

There was a safeguarding and whistleblowing policy in place which gave staff clear guidance to follow in the event they needed to refer any concerns to the local authority.

People and relatives told us they felt very safe and were treated well. Comments included, “Yes, there’s someone here, 24/7”, “I’ve got no worries” and “They know I don’t like the hoist, I close my eyes, but the staff reassure me. They’re so good”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Where people had specific health needs which place them at risk of harm, such as epilepsy and diabetes, risk assessments had not always been completed and the risks relating to these conditions had not been fully considered. For example, one person had a diagnosis of epilepsy, however there was no care plan or risk assessment in place for this condition to provide staff with information, guidance or advice on how to monitor, support and escalate concerns should the person become unwell or experience a seizure. We spoke with two staff who both told us that there were no people living in the service that had epilepsy.

Risks to people were not always effectively monitored. Some people were placed at risk of constipation due to the lack of guidance in care plans to support staff in managing the risk. For example, a person was assessed as high risk of constipation, however, there was a lack of guidance in place about the management of constipation. This included a lack of detailed information in relation to the ‘when required’ medicines that had been prescribed, when to give these or frequency of what a normal bowel pattern was for the person.

We were not assured people at risk of developing pressure injuries or people who had active pressure injuries had been repositioned in-line with their assessed need. For example, one person’s care plan stated, they had an active pressure injury and needed repositioning every 2 hours. On review of this person’s repositioning records, we found they had not always been repositioned as described and, on some occasions, repositioning was taking place between 2.5 hours and up to 7.5 hours. People were placed at risk of experiencing skin damage and for people with existing pressure injuries this placed them at risk of delayed healing.

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

The providers systems and processes in place were not effective and did not identify the concerns we found on inspection. The monthly monitoring of bedrails were being completed, however, these were not effective. We identified some protective bumpers that were not the correct length or appropriate for the bedrail, placing people at risk of entrapment.

Fire safety monitoring checks were not consistently completed when required. For example, we identified gaps in the testing of fire monitoring equipment, including the weekly fire alarm and the lack of oversight of staff participation in fire evacuation drills.

The provider lacked an effective system to manage risks associated with a bacterium called Legionella, which can proliferate in building water systems. We noted a lack of oversight of water temperatures and of an awareness of actions to take when they were outside the safe ranges.

Some areas of the home showed signs of wear and tear and were in need of refurbishment. The management told us there was a plan to redecorate the home.

The provider met the requirements in relation to mobility equipment including, nursing chairs, wheelchairs, hoists and slings.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider had not always ensured that staff received all training relevant to their role, this included ensuring that staff were suitably trained and skilled to support people with specific conditions such as epilepsy, diabetes and catheter care. The providers training matrix did not include any training for staff in relation to learning disability or autism and child safeguarding.

Whilst the service had a dependency tool in place, this was not robust and did not identify people's bespoke needs. People’s support hours were set by their assessed category of need for example, low medium and high rather than based on their specific requirements. This meant that people's dependency assessments did not accurately reflect the true level of support they required meaning some people were not always receiving the correct level of support to meet their needs, for example, the shortfalls we identified in relation to people's bathing and showering which is further detailed within the quality statement independence, choice and control.

We asked people and relatives if they felt there was enough staff on to meet their needs. Comments included, “No, not during the day. They need 2 or 3 more. They said they’d try to interview more staff”, “I think they probably could do with more. They’re [staff] never sitting still, they’re always dealing with things, so that probably indicates they need one or two more staff”, “No. Definitely not. I had to stop [person] from getting up in case they fell. There were no staff there. That’s not my job” and “No. I don’t know what the ratio of people to carers should be, but there’s 6 on in the morning and 5 in the afternoon. That sounds a lot, but if someone need hoisting, [person] needs 2 [staff] for that, and people have to wait”.

The provider did not always ensure that staff had supervisions in line with their own policy. The supervision tracker only contained details of staff’s most recent supervision. There were 4 staff that had not received a supervision since February 2025, and a further 5 staff who had not had a supervision since March 2025.

Staff had received annual appraisals with the exception of one staff member.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The providers systems and processes in place were not effective and did not identify the concerns we found on this inspection in relation to infection control.

We found areas of the home required additional cleaning and staff did not always ensure the environment was maintained to mitigate the spread of infection. For example, the bedroom of a person who was currently in hospital had an extremely strong smell of urine, stains on the carpet and stains up the wall. This had not been identified by any systems or processes in place. In addition, the window was dirty with liquid spills down it and there was a sealed plastic hospital bag containing dirty laundry in their wardrobe from a previous hospital discharge. We raised this with the management team who took immediate action and moved the person's belongings to a vacant bedroom. Following on from our visits the management sent evidence that improvements to the cleanliness for this bedroom had been made.

Other areas of the home required improvement such as decoration and replacement of flooring. We observed some bedroom carpets to be stained as well as some hallway carpets and a staircase carpet that had black tape on four steps due to the carpet being worn and frayed. Another person’s bedroom was found with drink stains up the wall by their sink. This person was cared for in bed and unable to access that area of their bedroom. Not all these concerns had not been identified by leaders, and they did not have appropriate plans in place for improving people’s environment.

Feedback from people and relatives around the cleanliness and maintenance of the home included, "It could do with a paint up. There’s stains up by the sink in [loved one] room, now [loved one] didn’t do that, they can’t get up, and I didn’t. The carers should be more careful. This chair I’m sitting on isn’t clean, it’s got splashes of thickened liquid on it", "All the important things are taken care of. It would be nice to have a lick of paint on the walls, but all the important things are in place, the showers work, and the toilets are clean" and "It’s mostly clean; they come round with the Hoover. If something gets broken it may take a couple of days to replace it, but they do it".

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The provider did not make sure that medicines and treatments were safely administered to people who had their medicines given covertly. The service had received specialist guidance from the pharmacist on how each medicine was to be administered. For example, advice given for one specific medicine clearly stated, ‘Do not use milk or carbonated water'. However, staff told us that all the medicines are crushed and put in the person’s cup of tea or bowl of porridge. We asked the staff if the person had black tea and porridge made with water, the staff member replied, "No with milk". Whilst expert advice had been sought and given to the service on how to ensure each medicine remained pharmaceutically active, this guidance was not followed therefore, we were not assured that these medicines remained effective.

The provider had a system in place to ensure food and fluid thickening power was safely stored, this included the thickening powders to be locked in a transportable box, however this system was not consistently effective. For example, on day 1 of our visit we found 2 tubs of thickening agent unlocked and accessible to people in a person’s bedroom. We informed the management team straight away and ensured this was locked immediately. However, on day 2 we found the transportable box containing 11 tubs of thickening power in the dining room which was unlocked and easily accessible to people. This was again immediately raised to the management team.

Feedback from people in relation to receiving their medicines when prescribed and pain relief was mostly positive. Comments included, “Yes, that’s regular”, “Yes, they’re good with that [pain relief]. They know to give them [pain relief] no more than every 4 hours”, “Yes, [loved one] never complains to me about being in pain” and “At first, they said they only give one paracetamol. I said that’s not right, I always took 2 even when I was a child. Now they give me 2”.