Southdown 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 legal regulation in relation to safe care and treatment.

This service scored 56 (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. Lessons were not always learnt to continually identify and embed good practice.

There was evidence of learning taking place across several areas of the service, although systems to embed this consistently were still developing.

Staff said handovers helped them learn about people’s needs and changes in their condition. Daily huddles were used to discuss safety issues, and leaders described the introduction of monitoring roles such as infection prevention and control leads and hydration leads. The provider had also implemented a six‑monthly review of incidents. While these systems generated learning, it was not always clear how findings were shared with all staff or monitored for sustained improvement. Relatives told us staff were “kind, patient and responsive” and communicated better during more serious issues, though everyday communication could improve.

Staff were supported to reflect on concerns and improve practice, but improvements were required to embed learning consistently and ensure all staff demonstrated shared accountability for safety and continuous improvement. The manager was working on developing a system to further learn from incidents and we will assess the effectiveness of this at our next assessment.

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.

Staff worked together to plan and deliver care that maintained people’s safety. Handover meetings between night and day staff included information about health needs, recent hospital appointments and changes in condition. Nurses demonstrated awareness of risks, including how to escalate concerns and when to involve external professionals. Staff described clear processes for managing deteriorating health, including liaising with GPs, respiratory nurses and end‑of‑life services.

Transitional arrangements were generally effective. Relatives told us the service had involved them well when people were admitted or discharged from hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately.

Staff had a clear understanding of safeguarding responsibilities and described how they would escalate concerns. Training covered safeguarding adults and staff could explain the types of abuse to look for. Safeguarding responses showed reflective learning, and the provider cooperated with the local authority during ongoing enquiries.

Relatives told us they felt the service took safety seriously, describing staff as “kind”, “supportive” and “caring”. One relative said, “I am grateful for the care and compassion shown to my [family member].”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found staff were appropriately seeking legal authorisation to deprive a person of their liberty where they felt this was required to keep people safe.

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, supportive and enabled people to do the things that mattered to them.

Staff involved people and relatives in discussions about care, and relatives told us communication improved when significant issues arose. People were encouraged to express their preferences, and on the whole staff were knowledgeable about risks to people’s safety and how to mitigate those risks. However, fluid charts reflected some institutional practice and people’s fluid records showed up to five drinks offered per day. Fluid charts also were not totalled and lacked information about target fluid intake amounts. This limited the provider’s ability to identify dehydration risks and adjust support accordingly.

Despite these issues, staff recognised when people needed reassurance or adjustments. For example, a staff member adapted their approach to support a person who was distressed during a hoist transfer, reducing stimulation and giving the person more space. Staff showed creativity in supporting people with eating difficulties and encouraging alternatives when meals were declined.

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

The environment contained multiple hazards that posed significant risks. We found first‑floor windows with inadequate restrictors, unsecured balcony doors, tied or inaccessible call bells, and trailing wires. Some bedroom doors leading to outside areas were unlocked, including a ground‑floor room where a person could exit unnoticed.

The front door was not secure, and visitors were able to enter without being greeted by staff, highlighting concerns around unauthorised access and the safety of people who might leave the home unsupervised. Hot water was intermittently unavailable in several rooms, affecting hygiene and comfort. Staff and relatives raised concerns that some rooms were cold.

Although staff presence reduced some immediate risks, environmental failings persisted.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Recruitment practices were in place to ensure suitable staff were employed. However, we saw at times these lacked evidence of interviews to ensure leaders reviewed staff’s competency, knowledge and values prior to employment.

There were sufficient staff on duty to meet people’s needs, inline with people’s dependency needs. Staff were caring and attentive, and relatives consistently praised their compassion and commitment.

Staff received regular training, supervision and appraisal. However, there was no record of mandatory training in learning disability and autism, despite this being a national requirement.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly

Staff generally followed infection control guidance and used appropriate personal protective equipment (PPE). We observed staff handwashing before personal care. Communal areas were clean, and there were no malodours. However, infection prevention and control (IPC) practice was undermined by environmental risks. Ripped furniture in multiple areas made effective cleaning difficult.

While staff demonstrated good understanding of IPC principles, and the provider completed regular audits, environmental failings meant people were not consistently protected from infection risks.

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.

People received safe and effective support with their medicines. Medicines were managed safely and stored securely. Staff were observed administering medicines in line with guidance, and controlled drugs were stored and recorded appropriately. Care plans provided clear guidance on how people preferred medicines to be given, including detailed Medication Administration Records (MARs) and protocols for as‑required and covert medicines. Staff demonstrated competency and had completed recent medicines management training.

People consistently received medicines as prescribed, and audits identified minor issues only. Staff could explain symptom control measures, and records showed timely involvement of external professionals where needed.