Southlands Court Residential Home

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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 44 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learned to continually identify and embed good practice.

Records we viewed did not consistently show there was a proactive culture regarding health and safety incidents or concerns, and that these had been effectively reflected upon and used to drive improvement.

Staff understood reporting systems and recording processes, however systems and processes for recording were not always completed. For example, there were multiple gaps in the recording of daily care for people.

The learning culture within the service had started to improve through the whole service safeguarding enquiry and support from health and social care professionals to improve how the service manages safety concerns. As a result, staff were responding more effectively to people’s risks. They were escalating them to relevant professionals, to ensure people received safe care and support specific to their individual needs.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

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. In part, these related to delay in seeking medical attention when people’s health had deteriorated and poor escalation of risks to relevant health professionals.

Escalation of risk protocols lacked significant detail to guide staff. For example, the pressure sore escalation protocol was not specific to Southlands Court and did not contain details of relevant health professionals to contact when indicated.

Since the concerns have been raised, the home manager was working more closely with health professionals to manage people’s risks proactively. This had included a discussion with a representative from the home’s GP surgery. Since the discussion, a plan had been set up for the home manager to report all falls to the GP surgery to review and ensure actions had been taken to mitigate future risks.

During our assessment, the service was receiving a significant amount of support from health and social care professionals to improve how the service managed 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.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly with other health and social care professionals.

We identified work was needed to develop more comprehensive mental capacity assessments. Mental capacity assessments were not person-centred. For example, assessments would start with the person’s name and then from there, referred to them as ‘his/her’, ‘her/him’ or ‘she/he.’

However, we did find the service was working within the principles of the Mental Capacity Act (2005) MCA and if needed, appropriate legal authorisations were requested to deprive a person of their liberty. Any conditions related to Deprivation of Liberty Safeguards (DoLS) authorisations were being met.

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.”

Staff demonstrated an understanding of what might constitute abuse and knew how to report any concerns they might have. Staff received safeguarding training, to ensure they had up to date information about the protection of vulnerable people.

There were policies for staff to follow. Staff confirmed they knew about the safeguarding adult’s policy and procedure and where to locate it if needed.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

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. Care and support was not always planned and organised with people, together with health and social care professionals, in ways that ensured continuity.

Southlands Court had been placed in a whole service safeguarding (WSS) enquiry, due to multiple safety concerns relating to a number of people receiving care at the service. In part, these related to poor falls management and poor pressure care management.

Risk assessments were contradictory and lacked detail. For example, a person’s mental health risks were deemed as ‘not required’. However, the person had dementia and experienced ‘sundowners.’ Sundowners or sundowning syndrome isa term used to describe a pattern of increased confusion, agitation, and restlessness that can occur in people living with dementia, particularly in the late afternoon and early evening. Another person’s skin care risk assessment stated they were at medium risk of pressure damage; however, the care plan audit dated 19 February 2025 stated a risk assessment was ‘not required’. A further person’s falls risk was not well managed. Their falls risk assessment dated 26 February 2025 stated they were at 'medium' risk of falls, their care plan stated they were at ‘high' risk of falls and their general risk assessment stated they were at 'low' risk of falls. The inconsistent recording resulted in confusing information for staff to follow, placing people at risk of inappropriate care and support.

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).

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

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. On 21 March 2025, we reviewed an incident report issued the fire service which was dated 23 February 2025. It stated there had been a leak through the fire alarm in one of the bedrooms and to not use electrics until inspected.

When visiting on 11 March 2025, we witnessed a person had been moved from their bedroom into the room in question to allow for their room to be redecorated due to mould damage. The person was using a profiling bed which was plugged in, and had wires exposed. The provider had failed to adhere to the fire service’s advice and had placed the person at risk of harm.

On 21 March 2025, our inspection found the person was no longer in this room, but staff had been using the room. There was electrical equipment currently in the room, although this was not plugged in. We observed a staff member was in the room, and despite raising this with the home manager the person was still sat in the room 20 minutes later.

There was no risk assessment of this bedroom in line with the advice from the fire service. We requested a risk assessment, but this was not received.

Fire safety management did not fully protect people or others within the building, placing them at risk of harm. There were no records relating to fire evacuation drills being completed and there was no fire evacuation plan. The ‘fire alarm system logbook’ stated, ‘It is recommended that every event affecting the installation should be recorded. Events are fire alarms, false alarms, failures, tests, outstanding works, or conditions.’The last entry, post site visit, was on 4 April 2025. The last entry prior to this was 9 August 2024. Therefore, the following dates and events were missing from this document:

1. Fire alarm due to water leak 23 February 2025.
2. Fire drill 7 April 2025.
3. Fire alarm work carried out 8 April 2025.

Poor maintenance of equipment placed people at risk. In the ground floor bathroom, the bath hoist/chair to support people to safely use the bath had not had its Lifting Operations and Lifting Equipment Regulations (LOLER) 1998 testing. At the time of the inspection the chair/hoist in the ground floor bathroom within the bath area had not been serviced since April 2023. Following our inspection, the provider had the bath/hoist chair serviced on 8 April 2025.

Areas of the service had not been properly maintained to ensure people received care in a safe environment. We identified several areas of the premises which needed attention, including the flooring in the downstairs bathroom; mould behind the bathroom taps and window frame; a broken spindle on the stairs; the stairlift electrical connection held together with tape; hallway carpet was loose and taped across the floor; an upstairs window did not have a restrictor in place; a loose radiator cover; damage to a fire door; a faulty bedroom door handle; emergency lighting not working in the main stairwell; surgical disinfectant hand gels not secured in holders on walls; and the stairgate was loose at the top of the main stairwell. There was general wear and tear to the medicines room. There was a hole in the wall with capped off wires exposed; the flooring was cracked by the door; the door frame was damaged; and the boxed in pipes cover was damaged.

The décor of the premises looked tired with a general feel of wear, tear and a lack of investment. We asked to see the provider’s maintenance/refurbishment programme and the response was ‘ongoing, to follow’.

Risks associated with the storage of substances hazardous to health posed a potential risk to people. We found a key on a hook above the door to the Control of Substances Hazardous to Health (COSSH) storage room. This meant unauthorised people, including service users, could potentially access hazardous cleaning substances. We asked the home manager to remove the key during our site visit on 11 March 2025. This action was promptly carried out.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staffing numbers on each shift were calculated using a dependency tool, based on the needs of each person. However, this was not always effective, meaning some people were left with no social interaction for long periods of time. 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 felt there were not always enough staff to meet people’s needs. They raised concerns about the removal of the ‘twilight’ shift, resulting in a reduction in staff numbers on the floor within the service. Staff commented, “We could do with an extra member of staff as I feel like we have some people here now with higher needs, and I think another person would compensate” and “I think maybe a few more staff would be good as we feel we are understaffed. We manage ok, but it would be helpful to have more people” and “For improvement I would personally say we would need one more person on the floor. Sometimes it can get a bit tight when people are asking for the toilet and both pairs of staff are trying to help people. Sometimes you are asking people to wait, so that would be a huge benefit to us and the residents.”

Health and social care professionals also raised concerns about the removal of the ‘twilight shift.’ Staffing concerns were raised with the provider and as a result, the twilight shift was reinstated.

The provider maintained a staff training matrix, to identify staff training requirements and attendance. Whilst some staff had completed all required training, there were multiple occasions where staff had not completed required training. This raised concerns that staff were not following best practice and were not qualified to provide safe care that met people’s individual needs.

Staff did receive supervision from the home manager, so they could discuss their learning and development needs and any concerns they may have. However, this was sporadic and not in line with the home’s expected frequency (every 6 weeks). There was dependency on the home manager to cover unexpected absences or when short staffed, resulting in manager duties being delayed.

A lack of experienced leadership from the home manager resulted in a lack of coordination in staff deployment. We saw several times during our visit where some people were left for periods of time with little or no interaction.

There were safe recruitment and selection processes in place. However, the provider’s recruitment policy was out of date. The policy was dated 30 January 2019, to be reviewed in January 2020.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider’s infection prevention and control policy was out of date and made no reference to Covid, as it pre-dated the pandemic. The policy was dated 8 May 2018, to be reviewed in January 2019. The policy had not been updated since May 2018.

However, 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 wore personal protective equipment (PPE) appropriately and were trained in infection control. Spot checks were carried out to ensure staff were wearing PPE correctly.

Hoists and other equipment were monitored and kept clean. Cleaning charts were in place and covered all aspects of the home.

Infection control audits were completed to ensure the safety of the layout and hygiene of the premises.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Risks associated with medicines requiring additional storage measures were not safely managed. We found not all controlled drugs were stored in line with the Misuse of Drugs Act (Safe Custody) Regulations 1973, and did not adhere to the home’s own medicines policy. The service's medicines policy dated 12 March 2025 stated: ‘Where a Service User is prescribed medication which is classified as controlled, then the additional requirements for storage, administration and recording contained in the Misuse of Drugs Act 1973, must be followed. The controlled medication must be stored in a locked container, stored within the locked metal medicine cabinet, which must be firmly fixed to a wall.’

The provider’s controlled drugs (CDs) audit dated 31 January 2025, stated, controlled drugs were stored and met the Misuse of Drugs (Safe Custody) Regulations 1973, and were all clearly segregated in a controlled drug cabinet. However, the audit dated 28 February 2025, stated, 'CD safe is insufficient to contain Just in Case (JIC) and CD items.’ There was no mention of an action plan to address this. A further audit dated 30 March 2025, did not raise any concerns about the storage of CDs and again there was no action plan.

Medicines management practices were not robust. Medicines management was not in line with the service's own medicines policy dated 12 March 2025, and National Institute for Health and Care Excellence (NICE) ‘Managing medicines in care homes’ guidelines March 2024. On reviewing 8 service user’s medicine administration charts (MAR), we found: there were gaps on medication administration charts (MAR) when medicines had been administered; handwritten entries on MAR charts were not always double signed; There were no ‘as required’ (PRN) protocols to guide staff and there were gaps in room and fridge temperature checks.