Southlands Residential Home Limited

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

People and staff were encouraged and supported to raise concerns and staff felt confident they could do this and would be treated with compassion and understanding.

There were systems in place to investigate any incidents which occurred within the home. Individual accident forms were completed with details about what happened and any immediate actions taken. We saw an example where a person had been falling from bed, and a crash mat had been introduced in response to help keep this person safe which promoted learning amongst the staff team.

People told us that when any incidents happened, including falls, appropriate action was taken. One relative told us, “I had been recommended this place by close friends who had relatives here, and I knew it was the right decision when I see how many improvements there have been for [person] in here with her health and emotions. If there is someone seriously ill, or an ambulance called, the staff keep everything tactfully running with dignity.”

Lessons were learned from safety incidents or complaints, resulting in changes that improved care for others. Staff told us lessons learned from safety incidents or complaints were shared during handovers, daily huddles and staff meetings.

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.

Initial assessments were completed when people first moved into the home, which provided staff with an overview of people’s care needs and how they needed to be met. Copies of these records were held within people’s care plans.

Records showed information about people was available and shared with health care services when needed. For example, ‘hospital passports’ were used which included key information about people’s health conditions. Hospital discharge paperwork was included with people’s care planning information to ensure safe transitions.

The registered manager explained they shared information with other providers when people moved from the service to different services to help new providers understand the person’s care needs. People’s care plans showed they received support from a wide range of other health professionals including speech and language therapy, dieticians, district nurses and doctors where needed.

There was a strong awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was proactive and effective. Staff told us how they recorded any concerns or changes such as pressure sores and the general wellbeing of people within the person's care notes. We also saw evidence of hospital admission documents being completed.

Care and support was planned and organised with people, together with partners and communities in ways that ensured continuity. The views of people who used services, partners and staff were listened to and considered. Policies and processes about safety were in place.

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.

People and their relatives said the service was safe. One relative told us, “I feel very confident leaving mum here and I know she is safe and looked after well. I come in 3 times per week and like to stay as long as possible.” A person said, “The staff are really good and look after us all very well. If there is anything bothering you, there is always someone to talk to or help you. I feel very safe in here, it’s very well organised.”

There was a safeguarding policy and procedure in place which was in date and provided an overview about what people could do if they experienced any abuse. A safeguarding log was maintained, with details about any incidents reported to the local authority for further review, although the registered manager told us there had not been any recent safeguarding incidents.

Staff had completed safeguarding training and understood how to report concerns. A member of staff said, “We report any concerns to senior staff or managers and if needed report directly to the local authority safeguarding team. I feel supported enough by management to know if I was to raise any concerns, they would take all the relevant actions to make sure people are protected.” The registered manager told us, “Management look at any safeguarding concerns, gather all the information, and seek advice from the safeguarding team and CQC. Feedback on safeguarding is given to staff at meetings.”

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 that DoLS applications were made to the local authority as required and the registered manager kept records about when these needed to be updated. Staff had completed training and understood why the legislation was required.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had individual risk assessments in place relating to the care and support they received. Where any risks were identified, control measures were detailed about how these needed to be managed. Personal emergency evacuation plans (PEEPS) were also in place for each person. Risk assessments were not always in place for each person however, for example, we found not everybody had a skin integrity care plan, or choking risk assessment in place. This meant there was a risk staff would not have all the correct information about people. Following the site visit people’s care records were updated accordingly.

People and relatives were involved with risks where possible, and we saw care delivery was reflective of the care people required. For example, where people were at risk of falls, appropriate equipment was available for people such as walking sticks and frames. Risk assessments about care were person-centred, proportionate, and reviewed. One person had a chair sensor in place due to being at risk of falls which helped staff know when they may try to walk unaided.

People were referred to other agencies for further support and advice if needed. One person said, “I had a chest infection a few weeks ago and the staff called the Doctor in straight away no messing about.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We walked around the environment to ensure it was safe for people living at the home. We found several window restrictors were not fully effective and allowed the window to open wide enough for someone to get out. The registered manager arranged for this to be rectified immediately. Not all radiators had protective covers on them which meant there was a risk people could burn themselves. Not all wardrobes were secured to walls which presented the risk of them falling on people. We spoke with the registered manager about ensuring these were installed and action was taken immediately.

There were regular visual checks of the environment to make sure it was safe and free from hazards. Essential servicing had taken place such as the maintenance of gas, water, the passenger lift and firefighting equipment. A fire risk assessment had been completed, and we saw any actions had been rectified, which included adding additional signage within the home to ensure people evacuate in an emergency.

The home had disabled access on the ground floor and there was a passenger lift available for people to access upper levels of the home if needed. Safety gates were used at the bottom of the stairs to reduce the risk of people falling who were unable to use the stairs independently.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing rotas were in place and demonstrated how many staff were available to care for people, and people told us there were enough staff available. Staff had the right skill mix to ensure people received consistently safe, good quality care that met their needs. We did not observe anybody waiting for staff assistance, and throughout the inspection we saw staff supporting people with tasks such as eating and drinking, mobilising and assisting in bedrooms.

Staff were recruited safely, with appropriate pre-employment checks carried out before staff started working with the service which included Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff had opportunities to learn, and any poor performance was managed appropriately.

Staff supervisions were infrequent and did not appear to take place regularly, although the providers’ supervision policy did not state how frequently these would take place. There was no evidence of staff appraisals being carried out and the registered manager told us these were done as part of supervision sessions. We spoke with the registered manager about ensuring this was a separate process so that staff could reflect and provide feedback on their performance and work towards set objectives.

People and relatives said staff had the necessary skills to carry out their role. A training matrix was used to record training undertaken by staff and showed staff had received training in areas such as moving and handling, safeguarding, infection control, and medication.

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.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. People were protected as much as possible from the risk of infection because premises and equipment were kept very clean and hygienic, and there were no offensive odours. Domestic staff completed daily and weekly cleaning schedules which were signed and dated to show they had been completed.

We found the home to be clean and tidy throughout and observed domestic staff carrying out their duties during the inspection. Hand sanitiser was available around the home and posters were displayed to encourage compliance.

Toilets and bathrooms were equipped with appropriate hand hygiene facilities such as paper towels and liquid soap, however, not all bathrooms had foot operated pedal bins, so people would need to touch the bin after cleaning their hands; we provided this feedback to the registered manager.

There was an up-to-date policy on the control of infection, prevention and control (IPC) which staff could refer to if needed. Staff were trained in IPC and had access to personal protective equipment (PPE) which we saw being used during the inspection.

Nobody raised any concerns with us about the cleanliness of the home during our inspection. One relative told us, “It’s so very welcoming and clean, it never smells.”

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.

Medicine administration records including those for controlled drugs showed people received their medicines as prescribed. People who had been prescribed medicines on a when required basis had written plans in place to inform the care staff of how and when it was appropriate to administer these medicines.

A system was in place for recording where on the body skin patches containing medicines were being applied. These records showed patches were being rotated around the different skin sites to comply with the manufacturer’s guidance.

All medicines were stored securely and at the correct temperature. Staff that administered medicines had completed safe management of medicines training and had undergone an assessment to check their competency to administer medicines safely. Processes were in place for the timely ordering and supply of medicines.

When people were refusing their medicines, their mental capacity was assessed and recorded, and people were supported appropriately. There was a process for medicines being administered covertly, including obtaining pharmaceutical advice from an appropriate health care professional.

Fridge temperatures were being measured using a maximum and minimum thermometer and therefore were able to demonstrate medicines were being stored at the correct temperature.