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 requires improvement. At this assessment the rating has remained 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.

This service scored 59 (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 learnt to continually identify and embed good practice.

Staff were increasingly adopting a proactive culture regarding health and safety incidents or concerns. However, further work was needed to ensure all concerns were reported and recorded appropriately to ensure people’s safety. This work needed embedding and sustaining in practice.

There was greater oversight of accidents and incidents which resulted in improved care for people. Lessons were learned to continually identify and embed good practice. Where improvements were needed actions were being taken. For example, further training for staff to understand how they contributed to people’s safe care and support and closer working relationships with health and social care professionals.

There was a focus on keeping people safe. There was evidence of health and social care professionals being referred to for advice in a timely manner. For example, to the community nursing team and GP.

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.

Professionals confirmed the service were escalating risk more effectively, but felt further work was needed to maintain safe systems of care.

Escalation of risk protocols were now in place, which guided staff on how to escalate risks to relevant health professionals. For example, a post falls assessment form had been implemented, which ensured the GP surgery was notified of all falls, timely referrals to the falls team were made, and there was input from physio and occupational therapists if required. A pressure damage assessment form had also been introduced. This had led to a reduction in pressure ulcers. However, the process for escalating risks needed further embedding and sustaining in practice to ensure people’s safety was managed and monitored.

Staff were working more closely with health professionals to manage people’s risks proactively. For example, with the community nursing team. Staff conversations were ongoing about reporting changes in people's presentation, skin health and forging better relationships with the community nursing team. A health professional commented, “There is an improved relationship with the community nursing team and good engagement with other services including the community therapy team.”

In addition, to further develop staff skills and confidence, escalation and deterioration of health training was booked for November 2025 with an external health professional.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People felt safe with the staff that supported them and felt able to raise any concerns.

Staff demonstrated an understanding of what might constitute abuse and knew how to report any concerns they might have. For example, staff knew how to report concerns within the organisation and externally to the local authority, police, and the Care Quality Commission.

Staff had received safeguarding training, to ensure they had up to date information about the protection of vulnerable people.

The management team demonstrated an understanding of their safeguarding role and responsibilities. They explained the importance of working closely with commissioners, the local authority and relevant health and social care professionals on an on-going basis.

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

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

We found 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.

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.

Risk management continued to need improvement. People’s individual risks were being identified more effectively, and the necessary risk assessment reviews were increasingly carried out to keep people safe. However, further embedding of risk management processes was needed to continually drive improvements in the way staff managed people’s risks. Professionals confirmed improvements had been made with how the service managed people’s identified risks, but there was still a lack of detail in some risk assessments and care plans.

Care and support plans contained improved guidance for staff about how to recognise and manage risks. For example, when people were experiencing emotional distress, or required support with acute health conditions. However, further work was needed to ensure they were updated when there were changes in people’s needs.

Staff awareness of people’s risks had improved. Staff were identifying and managing risk more effectively to keep people safe. Care and support was increasingly being planned and organised with people, together with health and social care professionals, in ways that ensured continuity.

Staff had received training on how to monitor, anticipate, and observe changes in behaviour. This helped them identify if people were unwell or upset and provide the support they needed.

Staff were aware of and knew where to find information about people's risks. Staff told us, changes relating to people’s care were communicated to them through several different channels, for example internal messages, handovers, and staff meetings.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People told us staff helped them feel safe without minimising their independence. They felt able to move freely around the home and spend the day as they wished.

The provider had invested in the premises. People’s individual needs were met by the adaptation, design, and decoration of the premises. People had a variety of spaces in which they could spend their time, and their bedrooms were personalised. Reasonable adjustments had been made to enable people to move around as independently as possible.

Fire safety management had improved and protected people and others within the building. Improvements continued to be made to the fire safety of the premises. This included a new fire panel and systems within the building to keep people safe.

Environmental risk assessments considered all aspects of the home, both internally and externally, to ensure people lived freely within a safe environment.

Risks relating to the physical environment had been identified and the necessary remedial actions were completed to ensure people’s safety.

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. A maintenance record was completed and repairs were completed in a timely manner.

Staff confirmed they had received relevant health and safety training, including fire safety, to carry out their roles to ensure the safety of people living in the home.

People had individual personal evacuation plans to guide staff in the event of a fire.

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.

There were incomplete recruitment records for some members of staff, which the provider had already identified and was addressing. For example, there was a lack of evidence of previous qualifications, there were gaps in employment history, there was no evidence of health questionnaires and no evidence of interview questions and answers.

The provider confirmed they had already identified the deficits within recruitment practices, which formed part of the service improvement plan. They had carried out an audit of all staff files on 19 September 2025. As a result, a 'missing information/gaps in employment' risk assessment had been completed of all existing staff files. A staff file tracker and recruitment risk assessments had been implemented and the management team were working at pace to rectify the issues as part of their ongoing workforce governance improvements.

Staff were deployed in line with people’s assessed care and support needs. Where additional staff were needed, as far as possible, consistent agency staff were utilised to support continuity of care. The service had been having difficulties staffing the ‘twilight’ shift, which covered between 6-11pm. A new twilight member of staff had been recruited and one more was needed. The provider was also recruiting additional staff. They commented, ‘Our recruitment drive will now include recruiting slightly above establishment levels to cover sickness and annual leave.’

On-call arrangements were not formalised at the time of our site visits. Following this, the provider confirmed, on-call arrangements were now in place. They commented, ‘On-call responsibilities are currently rotated between the manager and deputy manager, with plans underway to include selected and experienced senior care staff.’

Staff received relevant training in evidence-based practice specific to people’s individual care and support needs. Staff training remained one of the provider’s priorities to ensure staff were equipped with the knowledge and skills to support people in a person-centred way. Staff had also completed nationally recognised qualifications in health and social care.

Staff received supervision to enable them to feel supported in their roles and to identify any future professional development opportunities. However, this support needed to be provided in a more consistent way. The provider had identified staff supervisions were not up to date and was prioritising these as part of the service improvement plan.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There were effective infection control measures.

People confirmed the home was clean and tidy with a homely feel.

Staff wore personal protective equipment appropriately.

Staff were trained in infection control and said there was enough equipment to ensure effective infection control.

Equipment was monitored and kept clean. Cleaning charts were up to date, which covered all areas of the home.

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

The provider’s infection prevention and control policy was up to date and reflected current good practice guidance.

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

Medicines management practices had improved. However, further work was needed to embed the improvements in practice. For example, we found there were still handwritten entries on MAR charts which were not double signed. This was addressed with staff in a timely manner through additional supervisions following our site visits.

Staff followed systems and processes to administer, record and store medicines safely. They made sure people received information about medicines in a way they could understand.

Staff reviewed each person’s medicines regularly to monitor the effects on their health and well-being and provided advice to people about their medicines. There were ‘as required’ (PRN) protocols to ensure consistency.

Medicine storage temperatures were monitored and medicines were disposed of safely.

Risks associated with medicines requiring additional storage measures were safely managed. There were regular safety checks for these medicines.

Audits were undertaken to ensure people were receiving their medicines as prescribed. The checks also ensured medicines remained in date.