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Southfields House Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 12 December 2019

About the service

Southfields House is a residential care home providing personal care to 33 people with a physical disability, sensory impairment, dementia and mental health needs at the time of the inspection.

The service can support up to 45 people across six separate units, each of which have separate adapted facilities. 19 people lived at the home permanently and 14 people were temporarily staying at the home to receive reablement support at the time of inspection.

People’s experience of using this service and what we found

The service had a registered manager. However, they had been absent since July 2018. The provider had appointed an acting manager who was responsible for monitoring the quality of the service and ensuring the regulatory requirements were met. Quality assurance systems and processes identified where improvements were needed. However, we found action was not always taken quickly enough to resolve issues found.

Decision specific mental capacity assessments and best interest decisions had not been undertaken for all people that lacked capacity to make decisions about their care. However, we found people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff knew how to recognise, and report suspected abuse. They had been safely recruited and had access to the training they needed to meet people’s individual care needs. Staff had a good knowledge of infection control requirements and had access to personal protective equipment. Staff felt well supported by the management team.

There had been an increase in medicines errors and there were no protocols in place to instruct staff to administer medicines people were prescribed ‘as required’. Following our inspection, the service implemented protocols for ‘as required’ medicines and met with the GP surgery and pharmacy to develop a new system for ordering and stock control of medicines. People told us they received their medicines on time.

People told us they were happy with the food available and were able to choose what they wanted to eat and drink. Staff contacted health professionals as needed and had received specific training to meet people’s individual needs.

People were supported by staff that were kind and caring. Staff respected people’s privacy and dignity and involved them in decisions about their care. Staff knew people’s hobbies, interests, preferences and wishes and we observed staff talking with people about these. Activities such as crosswords, newspapers and jigsaw puzzles were available for people to use.

Complaints were managed in line with the providers complaints policy. People and relatives told us, they felt confident action would be taken should they complain.

The service understood their requirements in relation to duty of candour and were open and honest with us during our inspection. They worked with partner agencies such as commissioners and healthcare professionals to meet the needs of the people living at the service.

For more details, please see the full report which is on the CQC website at

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 29 December 2018)

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough, improvement had not been sustained and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.


We have identified a breach in relation to the governance of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our r

Inspection areas


Requires improvement

Updated 12 December 2019

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 12 December 2019

The service was not always effective.

Details are in our effective findings below.



Updated 12 December 2019

The service was caring.

Details are in our caring findings below.



Updated 12 December 2019

The service was responsive.

Details are in our responsive findings below


Requires improvement

Updated 12 December 2019

The service was not always well-led.

Details are in our well-led findings below.