Southlands Residential Home Limited

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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had a clear Statement of Purpose and vision and strategy for the service which the leaders were aware of. A senior staff member said, “Visions and values focus on safe, compassionate and person-centred care. I apply this by supporting staff, prioritising residents and promoting positive respect for everyone.” Staffs understanding of the organisation’s values were tested out at meetings.

The atmosphere in the home was calm and positive and reflected a supportive staff culture. A relative told us, “Since being in here [person] has definitely become much calmer; I cannot fault this place at all.” A range of different staff team meetings were held regularly to provide updates, to identify from staff’s perspective any potential gaps in quality, and to ensure as a service, the provider was meeting people’s needs, and leaders engaged regularly with the staff team. Feedback mechanisms had been set up which provided an opportunity for people and their relatives to have a say in care provision.

Satisfaction questionnaires had been sent to all people and their relatives, and the results had been analysed to support making improvements. Feedback from these questionnaires showed people were consistently happy with the care provided, and where they had made suggestions for changes, these had been listened to and acted upon.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders of the service were suitably experienced and qualified and had clearly defined roles and accountabilities. Several leaders had worked previously in the social care sector and so had the skills and competence to get involved in the direct delivery of care if required.

The provider ensured there was always suitable managerial cover; this included leaders being available to provide advice to staff throughout the night and at weekends. Staff told us they felt supported and received the necessary support and supervision. A staff member told us, “Leaders show compassion and professionalism and follow best-practice guidance. They support staff, prioritise resident needs and promote a positive and safe environment. Managers communicate regularly with staff and residents, conduct audits and hold team meetings; this helps to identify any problems early, and take action to improve care.”

Leaders were knowledgeable about issues and priorities for the service; they had access to appropriate support, including staff support groups and individual line management. Leaders had the opportunity to develop within their roles. Leaders took full responsibility within their roles and challenged poor performance when necessary.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us the felt able to raise concerns and that they would be listened to. There were mechanisms in place for staff to speak up and a culture in place to encourage them to do so.

Good communication was in place through team meetings, daily meetings and formal individual supervision sessions to ensure staff had regular opportunities to engage with leaders. This was also supported by policies and information supporting staff to raise concerns externally if required.

People and relatives felt their voice was heard. The provider had an up to date freedom to speak up and whistleblowing policy in place. We observed staff speaking to people and asking permission to support them. People were spoken to in a kind and respectful manner and staff were caring in their attitude and approach.

Without exception everyone we spoke with told us how well the home was run by the registered manager; they said the registered manager was very approachable and always available to chat and they stated staff worked as a great team and were enthusiastic about their jobs.

We looked at the results of the most recent survey. Analysis of the survey results showed people being supported were overwhelmingly pleased with the quality of care provided and how they were treated by staff members. Responses indicated people were comfortable with staff. In conclusion, people were happy with the support provided, resoundingly feeling supported in living their lives and doing as they wished. People felt they were secure around staff members, and could make their own decisions, with staff support.

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.

Leaders provided flexible working agreements to staff to account for personal circumstances such as caring responsibilities and health issues and had put reasonable adjustments in place for some staff to help them carry out their role. A staff member said, “The service offers flexible working, and it worked around [my family care needs.] Managers also adjusted my shifts around my college work.”

Leaders took steps to ensure staff were representative of the population of people being supported. Staff told us they were treated equally by leaders. A staff member told us, “I have no concerns about the way I am treated at Southlands; I am treated fairly and equitably.”

Managers engaged with staff via appropriate forums such as individual supervisions, various staff meeting types and staff surveys, to ensure their voices were heard. Staff were confident they could raise concerns directly with their leaders, and had received training in equality, diversity and human rights. The providers’ equality statement identified they were committed to equal rights and the promotion of choice, person centred care and independence.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Staff were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. A clear organisational staff infrastructure was in place.

The provider operated effective governance processes; audit systems ensured staff were undertaking regular audits, and analysis of recorded accident and incident data was in place to provide trend analysis and lessons learned. We found clear systems of recording and handover, which supported staff at all levels to work safely with people. Managers and staff were clear on the risks they faced and worked hard to make improvements and mitigate any risks. Performance and risks were routinely discussed in staff and leaders' meetings.

A range of operational meetings, were used to review data, including any incidents, complaints, weight loss, medication errors, and any further concerns. There were regular meetings, focusing on clinical risk and oversight of people’s assessed needs to ensure appropriate action had been taken.

The provider had a business continuity plan, which covered the relevant areas. Policies which were reviewed as part of this inspection had version control which ensured a review of them had been recorded.

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 for improvement.

The provider, registered manager and staff worked in partnership with local organisations and people were supported to engage with the local community, which had a positive impact on them. People’s daily lifestyle was identified in their care plans; this provided information on what each person was interested in and liked to take part in. The registered manager told us, “Within the framework of data protection, we share information with others to ensure continuity of care, safety, and healthy outcomes. We share only the information necessary and relevant to any given issue.”

People had the opportunity to take part in activities, and pictures of various activities were displayed around the home. A person told us, “I like some quiet times now and again and you only have to ask and they [staff] take me to my room. There are lots of activities going on here to join in with.”

Relatives told us people were invited to go on trips out or walks to the shops. A relative said, “It’s amazing this place and they [staff] have activities on every day; the ladies went to the garden centre the other day and the guys went to the pub with any relatives who wanted to go along with them. They have a curry night on a Saturday night. The carers are amazing, there is not one that doesn't go the extra mile, and they all know the individuals so well.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The provider had suitable systems and policies to ensure continuous learning and improvement. We noted lessons learned were in place and where concerns had been identified, these concerns were shared with the staff team. The registered manager was responsive to feedback from all sources.

The provider was committed in ensuring quality assurance was in place to maintain high standards of care and ensure the well-being of people being supported. There were clear and established standards for various aspects of care such as medication management and people’s safety. The provider and registered manager regularly reviewed incidents and medication errors, and any necessary improvement actions were recorded.

The provider regularly assessed the care provided through audits, internal quality assurance visits, and by analysing feedback from people and their relatives. Data including incident reporting and health outcomes was collected and analysed to identify areas for improvement. Meetings were held regularly to identify areas of concern.

The provider adequately trained staff and they understood the quality standards and procedures. All people we spoke with said they were very happy with how things were, and when we asked what they would change, they did not say there was anything they would change. We did not come across any negative comments from anyone we spoke with.

A person told us, “I feel very safe and cared for here. They [staff] really listen to you, and they really genuinely care. It’s ideal here, nothing is too much trouble. There is no time to sit around and be bored as there is always something going on but if you want to sit out you can. I have a daughter in [country name] and they [staff] help me ring or contact her so I can speak to her, considering the time difference. Staff will help you with anything that you need whatever that may be; you only need to ask them.”

All staff we spoke with confirmed leaders encouraged them to speak up with ideas for improvement and innovation and actively invested time to listen and engage; we also verified this by looking at a range of meetings which had taken place throughout the year.