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Inspection Summary

Overall summary & rating


Updated 28 July 2020

About the service

Southborough Care Home is a care home providing accommodation for up to 12 older people, including people living with dementia. At the time of the inspection there were 11 people living at the home.

People’s experience of using this service and what we found

We received information raising concerns about staffing and how people using the service were being kept safe. We wrote to the provider and asked for information around their systems and processes. This included policies, staffing rota’s, assessment of needs, the preferred times people wanted to get up and the current policy and procedure for managing people’s safety (safeguards).

We inspected the home from 06.00am to see how care was being provided against the information the provider had shared with us.

We received concerns that some staffing practice was institutional. We did not find any evidence to support this although staffing levels needed to be reviewed to ensure that people’s individual needs were met once they had got up and were within the communal areas. We made a recommendation regarding staffing.

We received concerns that safeguarding processes were not effective. We found evidence during this inspection that people were at potential risk of harm due to the poor management of safeguarding concerns. We identified a breach of Regulation 13 regarding safeguarding service users from abuse and improper treatment.

We also received concerns that staff were not following infection control guidance. During the inspection people were protected from the risk of acquiring infections and the service was clean. Personal protective equipment was available to staff and all staff were following the latest infection prevention guidance.

We received positive feedback from the staff team about the management of the service. However, systems and processes needed to be reviewed to ensure that the registered manager could demonstrate that people’s individual needs were being met with the staffing levels provided and the care they received. The registered manager was working closely with the local safeguarding team to reflect on the current practice within the home to ensure that lessons were learned and to make improvements where needed.

Rating at last inspection

The last rating for this service was Good (published 13 December 2018)

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about staffing levels, safeguarding concerns and infection control risks. A decision was made for us to inspect and examine those risks.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Please see the safe section of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Southborough Care Home on our website at

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas



Updated 28 July 2020

We have not changed the rating of this key question, as we have only looked at the part of the key question we had specific concerns about.

The purpose of this inspection was to check specific concerns we had about Southborough Care Home. We will assess all of the key question at the next comprehensive inspection of the service.



Updated 28 July 2020



Updated 28 July 2020



Updated 28 July 2020



Updated 28 July 2020