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Inspection carried out on 23 June 2020

During an inspection looking at part of the service

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 carried out on 21 November 2018

During a routine inspection

Southborough is a ‘care home’. People in care homes received accommodation and nursing or personal cars as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Southborough Care Home accommodates up to 11 people in one adapted building. At the time of our inspection there were 11 people living in the service.

At the last inspection, the service was rated good. At this inspection, we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serous risk or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered’ persons. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People were safe because staff supported them to understand how to keep safe and staff knew how to manage risk effectively. There were sufficient numbers of care staff on shift with the correct skills and knowledge to keep people safe.

The administration of people’s medicines was safe. Staff had been trained in the administration of medicines and had up to date policies and procedures to follow. Their competency was checked regularly.

People were supported with maintaining a balanced diet and the people who used the service chose what they would like to eat. chose. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

Staff had good relationships with people who used the service and were attentive to their needs. People’s privacy and dignity was respected at all times. People and their relatives were involved in making decisions about their care and support.

Care plans were individual and contained information about how people preferred to communicate and their ability to make decisions.

People were encouraged to take part in activities that they enjoyed, and were supported to keep in contact with family members. When needed, they were supported to see health professionals and referrals were put through to ensure they had the appropriate care and treatment.

Relatives and staff were complimentary about the management of the service. Staff understood their roles and responsibilities in providing safe and good quality care to the people who used the service.

Inspection carried out on 25 August 2016

During a routine inspection

This unannounced inspection took place on 25 August 2016.

Southborough Care Home provides care and support for up to 12 older people, some of whom may be living with dementia. At the time of our inspection, there were 12 people living at the home. The home had a variety of animals with which people could interact.

The home had a registered manager, as is required by the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During our inspection we found that people were safe at the home. Staff were aware of the safeguarding process. Personalised risk assessments were in place to reduce the risk of harm to people, as were risk assessments in relation to the running of the home. These were reviewed regularly. Accidents and incidents were recorded and the causes of these analysed so that preventative action could be taken to reduce the number of occurrences. There were effective processes in place to manage people’s medicines and referrals to other health and social care professionals were made when appropriate to maintain people’s health and well-being.

There were enough skilled, qualified staff to meet people’s needs. Staffing levels had been based on the dependency levels of the people who lived at the home. Robust recruitment and selection processes were in place and the provider had taken steps to ensure that staff were suitable to work with people who lived at the home. Staff were trained and supported by way of supervisions and appraisals.

People or relatives acting on their behalf had been involved in determining their care needs and the way in which their care was to be provided. Their consent was gained before any care was provided and the requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were met. People and their relatives were involved in the regular review of people’s care needs and relatives were kept informed of any changes to a person’s health or well-being.

People had a choice of good nutritious food that they liked and their weight was monitored, with appropriate referrals made to other healthcare professionals when concerns were identified.

There was an up to date complaints policy in place and a notice about the complaints system was on display at the entrance to the home. There was information on the notice boards around the home about the service and organisations that could be contacted for support or to report concerns.

There was a very friendly, family atmosphere at the home. People, relatives and staff were able to make suggestions as to how the service was provided and developed. An effective quality assurance system was in place.

Inspection carried out on 10 October 2013

During a routine inspection

People who lived at Southborough Care Home had a range of needs including those associated with dementia. Where people were unable to tell us directly about their experiences, we observed that they appeared calm and relaxed; they interacted positively with staff and actively sought staff out. People who were able to speak with us told us that staff were kind and caring. One person told us: �I am very happy here, the staff are very patient and the food is lovely.� Another person told us: �The staff are very kind and helpful: they understand me.�

We observed that staff were attentive to people`s needs and treated them with respect and dignity. We saw that staff sought people`s agreement before providing any support and assistance. A relative told us: �This home is excellent; a nice environment, very calm and quiet and people are given choices and treated respectfully. I would recommend it.�

We saw that fresh cold drinks, snacks, sweets and fresh fruit were freely available and accessible to people in all areas of the home.

People had care plans in place that guided staff as to the care and support they needed. We found that the people living at the home were cared for by staff who received a good level of training and support from the provider and manager.

We found the provider had a complaints management system in place and although complaints were minimal; where they had occurred the management team at the home had dealt with them appropriately and objectively.

The provider had systems in place to monitor and to help ensure quality and safety at the home.

Inspection carried out on 15 October 2012

During an inspection in response to concerns

During our inspection we had conversations with four people living in the home. They told us that they were happy living in the home and that staff were helpful and supportive. However, two friends of a person previously in the home contacted us prior to our inspection. They raised concerns about the standards of care and the extremely defensive attitude of staff when they raised concerns. We phoned two relatives following our inspection. One relative said that they were very happy with the care and had no concerns. The other relative felt that the home was often short staffed, so that staff were not always able to deliver the standards of care that they promised.