Southlands Court Residential Home

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 changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 50 (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 understand the challenges and the needs of people and their communities.

The provider’s statement of purpose, reviewed on 17 March 2025, was not adhered to. One of the service’s aims and objectives was to provide, ‘safety and comfort to maintain a safe, clean, and comfortable environment that meets the highest standards of care and complies with all regulatory requirements.’ This aim and objective was not met, as evidenced throughout this assessment report.

Staff did demonstrate a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service.

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.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The provider did not always demonstrate the experience, capacity, capability and integrity to ensure the organisational vision could be delivered and people’s risks managed. They were not always alert to any examples of poor culture that may affect the quality of people’s care, as evidenced throughout our assessment of Southlands Court.

Staff did not always feel they could speak up and that their voice would be heard.

Staff told us they did not have confidence in the provider and felt frustrated by the lack of remedial actions to resolve issues which had been raised about environmental concerns, staffing levels and unsafe working practices.

The provider’s whistleblowing policy was out of date. The policy was dated 31 January 2018, to be reviewed in in January 2019.

The service valued diversity in their workforce. The home manager worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff felt supported to give feedback and were treated equally, free from bullying or harassment. People with protected characteristics felt supported.

Comments included, “I think [home manager] is doing a really good job, but it does seem quite hard on her at times but with what she has got to do I think she has done a pretty good job of it. Yes, she very much supports staff and listens to them, and she is always there if we need anything, so she is very supportive” and “[Home manager] is doing very well. She manages the floor, and she is very kind to the residents and the staff, and she tries her best. She is easy to talk to and yes, I would say all staff are treated fairly and equally. We also have had meetings with (home manager) like supervisions and you go and talk to her and can suggest changes and she does her best to implement changes by taking it to [provider].”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We requested from the provider additional electronic evidence as part of our assessment. We did not receive all the requested evidence. Therefore, they were not meeting legal requirements. As a result, we served a Section 64 letter. We required this information under our powers as set out in Section 64 of the Health and Social Care Act 2008. Section 64 gives the Care Quality Commission (CQC) the legal power to require certain persons to provide it with information, documents, records (including personal and medical records) or other items that the Commission considers it necessary or expedient to have for the purposes of its regulatory functions. We requested the information to be sent to us by no later than 5pm on Friday 11 April 2025. We did grant the provider a short extension until 9am on Monday 14 April 2025, which was met.

The provider had not established nor operated effective systems and processes to assess, monitor and improve the quality and safety of the service. There were some quality assurance systems and processes to monitor the service, but they were not effective. Risks were not mitigated, and governance systems had not identified the areas requiring improvement.

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. This did not evidence a proactive approach to risk management and mitigation and placed people and staff at increased risk.

Systems and processes had failed to highlight and address improvements for administration, recording and storage of medicines and did not follow national guidelines for safe medicine practice. For example, related to the unsafe custody of controlled drugs, gaps in medicine administration records, and poor medicines management in general.

The provider did not ensure any risks to delivering care and support, including relevant local factors, were understood. There was not a robust business continuity plan. It did not contain relevant contact details for emergency services, senior staff or contractors to contact in the case of emergency.

We found that the service did not have robust systems and processes to ensure accurate, complete and contemporaneous records for each person. Records relating to people’s care and treatment were often incomplete and out of date. For example, we found people did not have their baseline weight recorded on admission, life histories had not been explored or documented, there was no evidence of end-of-life care planning and daily notes contained gaps and lacked meaningful context about how people spent their days. This did not evidence good oversight of people’s assessed risks to their health, safety and welfare to ensure appropriate care and support.

Policies and procedures were not current or in date to support best practice within the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Staff and leaders were open and transparent. However, they had not always collaborated well with all relevant external stakeholders and agencies. For example, escalating safety concerns. This had improved throughout the whole service safeguarding enquiry. As a result, staff and leaders were working in partnership more effectively with key organisations to support care provision, service development and joined-up care.

Professionals commented, “The home is now more settled. Any required actions have been put into place and are ongoing. Staff morale has improved, and [home manager] is more settled. No concerns have been raised” and “It is acknowledged that a huge amount of work has taken place and [home manager] has a positive relationship with professionals.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service had not always engaged well with external professionals to support improvement and innovation within the home. For example, escalating safety concerns when people’s health had deteriorated. This 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.”