Archived: Southlands Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 54 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Our observations of people's experience and people's feedback demonstrated the provider did not consistently prioritise people's dignity, equity and inclusion and ensure their rights were upheld. The providers regulatory history and previous ratings did not demonstrate that the shared vision and strategy in place was effective in making the required improvements.

The provider worked with the staff team to build open and transparent relationships; this was demonstrated through staff meeting minutes that we reviewed.

People and their relatives were provided with clear information on how to raise suggestions and concerns about the service.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

Leaders did not always have the skills, knowledge or experience to ensure national guidance and regulations were always followed. The concerns we found during this assessment had not been identified by the management team prior to our visit. Therefore, we were not assured all managers had full knowledge and experience of the requirements of the regulations.

The management and staff team were approachable and appeared passionate about their roles. However, on review of staff questionnaires these recorded several times by different staff the need for improvement with communication from the management through to the rest of the home and in between departments. There were no records to demonstrate actions taken and outcomes of these.

People did not always feel they could speak up and that their voice would be heard.

Not all staff and relatives who were involved in people’s care felt they could always speak up and would be listened to. Comments included, “They listen, and they say things will change but they don’t always change” and “[Manager] says what you want to hear. What you want, never happens”.

Staff questionnaires had raised issues, however; there was no outcomes recorded as to what actions the manager had taken in response. For example, staff had raised concerns about the safety of the back garden as there was currently no suitable patio space to safely take residents to. Feedback from a relative during our inspection corroborated this had not been actioned and commented “No, [manager] doesn’t get things done and they put it down to a lack of money. There are humps and bumps in the garden, you can’t go out there. You can’t take a wheelchair out there”. Another comment included someone feeling “fobbed off” after raising a concern to the registered manager.

Whistleblowing policies were available for staff with advice about who to contact if they had concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider’s equality and diversity policy covered the 9 protected equality characteristics, so staff were provided with written guidance on how to ensure people or the staff team were treated fairly and equally regardless of any protected characteristics. A staff member told us they were treated fairly, and their human rights were upheld.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had a range of quality monitoring procedures in place including audits of various aspects of the service. However, audits and governance procedures were not effective and had not identified the issues we found during the inspection as detailed in the various sections of this report.

The systems and processes in place failed to ensure people’s records were always detailed, complete or contemporaneous. We found examples where people’s care records were incomplete, insufficiently detailed and did not contain sufficient information for staff to manage people’s specific needs or conditions. Risk assessments had not always been completed for known risks and people were not always repositioned as per their assessed need. The care plan audits we reviewed for June and July contained the same concerns and had not been updated straight away.

Additionally, the concerns we found in relation to safe medicines management and mental capacity assessments had not been identified through the providers audits.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated with them in delivering people’s care.

We saw evidence of external health professionals being involved in people’s care such as GPs, community specialist nurses and chiropodists. We received positive feedback from an external health professional in relation to the staff's care delivery related to a person's medical condition.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Although the provider was responsive to our feedback during this assessment, they were unable to demonstrate they had made and sustained improvements at the service where shortfalls had previously been identified. For example, at the previous inspection we identified a breach of regulation relating to person centred care, at this inspection the care plans continued to require improvement as these still did not contain sufficient guidance to support staff to understand people's wants, wishes and preferences.