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 requires improvement. At this assessment the rating has remained 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.

This service scored 61 (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 have a clear shared vision, strategy and culture which was based ontransparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities

The provider’s vision, strategy and culture, with staff knowing their role in helping to achieve this, needed embedding in practice. Work was ongoing to address this, through a strengthened management team and systems and processes being implemented. For example, through supervisions, team meetings and role modelling. This was to ensure all staff demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service.

The provider’s statement of purpose had been updated to outline the aims and values of the service.

Staff were able to demonstrate an understanding of equality, diversity and human rights to meet the needs of people living at Southlands Court.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider had 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. The management team 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.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People were supported to raise any concerns and were able to meet with the management team if required.

The provider promoted an open and inclusive culture which sought the views of people using the service and staff. There was dialogue with people who used the service, capturing their views and listening to their experiences. This helped to continuously improve the service they received.

The provider’s whistleblowing policy had been reviewed on 12 November 2025. This meant, people had up to date information on the procedure followed, if they raised any concerns.

The provider valued diversity in their workforce. They 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.

The provider valued and listened to the views of staff. Staff were given opportunities to provide feedback about the service and their opinion was valued. Staff commented, “Since CQC’s last visit, things have been taken on board very seriously, things are improving and staff morale has picked up because they're happier” and “It’s so much better here. We finally have someone who will listen to us. We feel we can talk to [names of members of the management team], they don't make you feel stupid for asking, we have the support we need.”

Staff were kept up to date with issues affecting the overall service via team meetings and conversations. Additional meetings took place on a regular basis as part of the service’s handover system to ensure consistency of care and support.

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

The provider had recruited a care consultant to support the service to ensure people received safe, effective and high quality care. Improvements were evident during our assessment. These needed further embedding and sustaining in practice to ensure people received consistent care and support which met their care and support needs.

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 identified areas where improvements were needed. For example, to medicines management, the safety of the premises and work required to people’s individual care and support plans and risk assessments. These systems and processes needed embedding and sustaining within the service.

We found systems and processes had been implemented to ensure accurate, complete and contemporaneous records for each person. However, further work was needed to ensure consistency of recording in people’s daily notes and monitoring charts.

An audit schedule had been implemented, to enable any trends to be identified and ensure the service was meeting the requirements and needs of people being supported. Where actions were needed, these were being followed up. For example, care plans and risk assessments were being updated, and relevant health and social care professionals were being involved. Any actions formed part of the home’s on-going service improvement plan.

A 'governance at a glance' document had been introduced for greater oversight of the service. The document evidenced where follow-ups were needed. For example, emails to staff reminding them of training deadlines, spot checks of hand hygiene and reminders to staff of the importance of daily notes and monitoring charts being completed.

Provider visits were undertaken, which looked at all aspects of the service. Any actions formed the basis of the home’s on-going service improvement plan.For example, relating to the need for more personalised detail in care and support plans. In addition to this, we received assurance reports from the provider on 22 August and 17 October 2025, outlining the continued progress at Southlands Court.

The provider ensured any risks to delivering care and support, including relevant local factors, were understood. There was a robust business continuity plan. It contained relevant contact details for emergency services, senior staff or contractors to contact in the case of emergency.

Policies and procedures had been reviewed and updated to support best practice within the service.

The service was open, honest, and transparent with people when things went wrong. The management team recognised their responsibilities under the duty of candour requirements and followed the service’s policies and procedures.

The service had notified CQC about any significant events at the service. We use this information to monitor the service and ensure they respond appropriately to keep people safe.

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. They collaborated more effectively with relevant external stakeholders and agencies. For example, escalating safety concerns to health professionals. Staff and leaders worked in partnership more effectively with key organisations to support care provision, service development and joined-up care. This work needed to be sustained and embedded in practice to ensure people’s care and support needs were met in a timely manner.

People confirmed their needs were met by staff in partnership with relevant health and social care professionals.

The provider and their management team were positive about their links with local partners and health and social care teams. They expressed an open, positive attitude to receiving support and understood how and where they could access support.

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.

Opportunities to learn from incidents were taken and learning was increasingly shared across the organisation. This work needed further embedding and sustaining in practice to ensure all opportunities to learn were taken.

The service’s service improvement plan evidenced extensive work 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.

The provider and their management team accessed best practice learning resources and kept up to date with changes in the social care system.