- Care home
Southlands Court Residential Home
Assessment report published 14 July 2025
Contents
Ratings
Our view of the service
Date of assessment 11 March to 19 May 2025. We visited the service on 11 and 21 March 2025. Southlands Court Residential Home is a residential care home providing care and support to a maximum of 26 older people. At the time of our assessment there were 26 people living at the home.
The assessment was carried out as we had concerns in relation to delays in seeking medical attention when people’s health had deteriorated, poor escalation of risks to relevant health professionals, poor falls management and poor pressure care management. There were also concerns about the leadership and management of the service and a lack of oversight from the provider.
There was a lack of awareness of people’s risks. Staff did not always identify and manage risks proactively and effectively to keep people safe. Risk assessments were contradictory and lacked detail.
The provider did not have good oversight of all aspects of the premises. Health and safety checks were inadequate in identifying and addressing safety issues related to the environment.
The provider had failed to fully mitigate fire risks associated with the safety of the premises. Fire safety management did not fully protect people or others within the building, placing them at risk of harm. Poor maintenance of equipment placed people at risk.
Areas of the service had not been properly maintained to ensure people received care in a safe environment. The décor of the premises looked tired with a general feel of wear, tear and a lack of investment.
Risks associated with the storage of substances hazardous to health posed a potential risk to people. Risks associated with medicines requiring additional storage measures were not safely managed. Medicines management practices were not robust.
The provider had not established nor operated effective systems and processes to assess, monitor and improve the quality and safety of the service. Quality assurance systems and provider level auditing had failed to identify important fire safety measures, moving and handling equipment requiring actions, environmental risks and risks associated with substances hazardous to health.
There were not robust systems and processes to maintain accurate, complete and contemporaneous records in respect of each person. Policies and procedures were not current or in date to support best practice within the service.
Lessons were not always learned to continually identify and embed good practice. Staff told us they did not have confidence in the provider and felt frustrated by the lack of remedial actions to resolve issues such as environmental concerns, staffing levels and unsafe working practices.
The provider did not always make sure there were enough qualified, skilled and experienced staff.
Southlands Court had been placed in a whole service safeguarding (WSS) enquiry on 13 February 2025, due to multiple safety concerns relating to a number of people receiving care at the service.
During our assessment, the service was receiving a significant amount of support from health and social care professionals to improve how the service manages safety concerns. As a result of improvements to risk management within the service, on 1 May 2025, it was agreed the thresholds for WSS were now not met. It was recognised work was still needed to embed and sustain the improvements in the service. As a result, the provider was placed in a formal provider quality support process (PQSP) coordinated by Devon County Council. PQSP establishes a formal means of responding to provider concerns where thresholds for whole service safeguarding adult enquiry are not met, but where there is a clear need for service improvement to minimise the risks presented to service users by the quality of care being provided.
We found 2 breaches in regulations in relation to safe care and treatment and good governance.
We served a warning notice on 23 May 2025 which gave a timescale to address breaches of regulations linked to safe care and treatment and good governance. The provider did not make representations against the warning notice.
People's experience of this service
Despite the concerns identified, people felt safe with the staff that supported them and felt able to raise any concerns. People and their relatives commented, “Yes, they look after me well. I feel safe, they check on me regularly”, “I know dad is safe when I leave here” and “I feel safe and looked after.”
Effective infection control measures were in place. People confirmed the home was clean and tidy. Comments included, “We’ve a good cleaner who comes in every day” and “It’s good, they clean the carpets regularly.”
Staff at all levels demonstrated an understanding of equality, diversity and human rights, and they prioritised compassionate care. People commented, It’s excellent care. The staff are good…They are brilliant”, “[Staff] are very respectful and kind. They always knock before coming in” and “[Staff] are always nice and polite.”
People told us, although staff were kind and caring, they often had to wait long periods of time for staff to answer call bells.
Staff confirmed they were able to raise concerns when needed. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. People with protected characteristics felt supported.
Engagement with external professionals had improved through the whole service safeguarding enquiry. As a result, staff were working more effectively with professionals to embed evidence-based practice, in order to deliver equality of experience, outcome and quality of life for people. A professional commented, “I am actively visiting the service and have provided pressure ulcer prevention training and management of skin tear training. [Home manager] and the team had managed a skin tear appropriately and prevented a 111 call. There are positive relationships with staff and management.”