- Care home
Southlands Court Residential Home
Assessment report published 8 January 2026
Contents
Ratings
Our view of the service
Date of assessment: 30 October to 27 November 2025. We visited the service on 30 October and 4 November 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 20 people living at the home.
The assessment was carried out as we had continuing concerns in relation to delays in seeking medical attention when people’s health had deteriorated, and poor escalation of risks to relevant health professionals.
The provider was previously in breach of the legal regulation in relation to safe care and treatment and good governance. Improvements were found at this assessment and the provider was no longer in breach of these regulations.
The service was currently in a whole service safeguarding (WSS) process coordinated by Devon County Council due to concerns in relation to the lack of identification and escalation of people’s risks to relevant health professionals. This was the second time, in close succession, the service had been in a WSS process due to similar concerns. The last time was between February and May 2025. Southlands Court was receiving support from various health and social care professionals to improve safety in the service and their governance systems and processes. As a result of this support, improvements had been made as agreed at the follow-up WSS meeting on 13 November 2025.
Staff were increasingly adopting a proactive culture regarding health and safety incidents or concerns. Risk management had improved and staff were escalating risks to relevant professionals in a more timely way. This work needed embedding and sustaining in practice. Professionals confirmed the service were escalating risk more effectively, but felt further work was needed to maintain safe systems of care.
The provider had invested in the premises. Fire safety management had improved and protected people and others within the building. The provider undertook regular health and safety checks of the premises as part of their auditing system. Risks associated with the storage of substances hazardous to health were well managed. Safety systems and equipment used at the service were maintained and serviced at regular intervals to make sure these remained in good order and safe for use.
There were incomplete recruitment records for some members of staff, which the provider had already identified and was addressing. Staff were deployed in line with people’s assessed care and support needs. The provider was recruiting additional staff.
Medicines management practices had improved. However, further work was needed to embed the improvements in practice. There were effective infection control measures.
People had care and support plans, which required further work to ensure they were personalised, holistic, strengths-based and reflected their needs. Care and support plans were being reviewed at pace, in collaboration with people, and personalised detail was being added as part of the provider’s service improvement plan.
Daily notes and monitoring charts did not always evidence care and support plans were being followed. It was established this was a recording issue only. This was being addressed through increased monitoring by the management team and the introduction of daily checks, and reinforcement with staff of the importance of accurate clinical documentation for both safety and regulatory assurance. As a result of the additional scrutiny, compliance was improving. The provider recognised improvements needed to be sustained and embedded in practice.
On one occasion, undignified terminology was used by a member of staff. This was in relation to a description of how people were supported with their meals. We discussed this with the management team who addressed this through implementing guidance and sourcing additional training for staff.
During our first day on-site, we saw limited staff engagement with people which was meaningful. Care and support was task orientated. On our second day, this had improved and staff were engaging well with people.
The provider had recruited a care consultant to support the service in moving forward to ensure people received safe, effective and high quality care. They had also appointed a new home manager, who would be registering with the Care Quality Commission. They were due to start in post a few days after our visits to Southlands Court.
The provider was alert to any examples of a poor culture which may impact on the safety and quality of people’s care and support. They informed us they were establishing a more robust framework to ensure all performance and conduct issues were formally documented and managed in line with policies and procedures, should action needed to be taken to mitigate future risks.
Improvements had been made to how the provider assessed, monitored and improved the quality and safety of the service. Risks were increasingly being mitigated, and governance systems were identifying areas where improvements were needed. These systems and processes needed embedding and sustaining within the service.
The service improvement plan evidenced extensive work was being undertaken to ensure people received safe, effective and high quality care. This, coupled with the increased positive collaboration with health and social care professionals, including the local authority, demonstrated the provider’s goal to deliver equality of experience, outcome and quality of life for people. This work needed to continue to be sustained and embedded in practice.
People's experience of this service
People confirmed they felt safe with the staff that supported them and were able to raise any concerns. Comments included, “I like it here. Everyone is kind and helpful. Definitely kind. They look after me, I’m very happy with the people”; “Staff check on me regularly”; “I don’t feel unsafe”; and “I don’t need a lot of looking after. I haven’t fallen since I’ve been here, they make sure I’m safe.”
We received mixed feedback about staffing on our first day on-site. This had coincided with a member of staff calling in sick at short notice. Comments included, “Staff are always in a rush as they have got work to get on with. If you need them to help you, you have to wait. I am lucky, I can look after myself. Staff levels can vary”; “The staff levels are not right. They work so hard. They shouldn’t work as hard as they do. They are always running around. Occasionally you have to wait a while for call bells to be answered”; “They have been very good; they are trying their hardest. They are being pushed to their limits” and “The staff are OK. They could do with more.” The provider was currently recruiting additional staff.
We received mixed feedback about people’s involvement in developing their care and support plans. Comments included, “They’ve [staff] got a care plan here somewhere. I don’t know what the management’s input into it is, it’s not been discussed. I’ve heard them mention it”; “I have left this with my daughter to sort out”; “My son lives locally and handles all aspects of my care” and “My sister lives locally and deals with mum’s affairs.” The provider was addressing this as part of the service improvement plan.
We received mixed opinions about activities. People commented, “I stay in my room. I know there is bingo every Friday. There’s no regular things to do, I prefer just to sit and read”; “It’s the same activities all the time. I like to play cards, but I can’t get anyone to play cards with”; I don’t know about any activities, we don’t get a sheet or told”; “Mum’s room is isolated within the home and I know she gets bored”; “We were out in the garden in the summer”; “At Christmas, the local school come which I really enjoy and on your birthday you get a cake” and “We have quizzes and make things. People stay in their rooms more now than they used to.” The provider was in the process of developing activity provision for people to enjoy.
People confirmed they received their medicines in a timely and safe manner. Comments included, “It’s usually the same member of staff who does the meds. They are very good. They [staff] stay and watch me take them”; “I get my meds three times a day, it’s always on time” and “They [staff] are very strict on meds, they are always on time.”
People felt staff were kind and caring. Comments included They’ll [staff] do anything for you. They are always nice and polite, good as gold. All of them I cannot fault”; “The staff are caring” and “The staff are lovely; they are caring but busy.”
People confirmed they were able to access care and support from staff as and when required. People commented, “Someone comes here to test my eyes. I would tell the staff if I felt unwell. I’d ring the bell and tell someone”; “The doctor has been when I needed them. The chiropodist is regularly here” and “I tell them [staff] if I am unwell. I ask to speak to the one in charge and ask to be put on the list to see the doctor when he calls weekly.”
People confirmed they generally enjoyed the meals on offer. Comments included, "The meals are very nice”, “We chose our lunch the day before. Fish and chips tomorrow, but I'll have egg and chips. I had a jacket potato today, as I don't like stew” and "I enjoyed my lunch. Lamb stew, green beans and new potatoes."