We carried out a review of the data available to us about Southways Group Ltd on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Southways Group Ltd, you can give feedback on this service.
Southways Group Ltd provides care and support to people living in specialist housing. At the time of the inspection, people lived in an adapted household accommodation in a shared site or building. The accommodation is rented and is the occupant's own home. People's care and housing are provided under separate contractual agreements. CQC does not regulate the premises used for this type of housing; this inspection looked at people's personal care and support service. At the time of the inspection five people were being supported with personal care.
People’s experience of using this service and what we found
The previous inspection in December 2019 found that standards relating to the quality and safety of the service needed to be improved. The provider had not always recorded areas of risk; safeguarding concerns were not raised with the appropriate bodies; the way people's medicines were managed needed to improve and staff had not received all the training they required, especially in relation to mental capacity and infection control. Care plans did not contain all relevant information about people’s needs and had not been reviewed to ensure their care and support was relevant and up to date. Accidents and incidents monitoring, governance systems and quality audits were not robust enough to ensure the management of the service was effective.
Improvements had been made throughout the service.
People who were able to talk with us over the telephone told us they were safe using the service. Family members told us their relatives were being cared for by staff who knew them well. Health and social care professionals thought the service had improved and people had better outcomes.
People were cared for by staff who were reliable and consistent. Rotas were organised in a way which meant people saw the same team of staff so that relationships were developed and maintained.
Staff had a good understanding of safeguarding processes to keep people safe and how to report any concerns. Staff understood and were aware of their responsibilities to raise concerns and report all incidents. People were supported with their medicines when they needed them. We were assured the service met good infection prevention and control guidelines and personal protective equipment (PPE) was readily available. There were enough staff to provide care and support to people and staff had been suitably recruited to their role.
Staff were aware of people’s needs and supported them to manage risks to their safety whilst supporting them to have maximum choice and control of their lives. Staff supported people in the least restrictive way possible and in their best interests. The policies and systems in the service supported this practice.
People’s needs had been assessed and reviewed. Care plans contained information about people’s needs and ways in which they should be met. This included their routines, preferences, and more recently, gathering information about their protected characteristics, culture and lifestyle.
Staff confirmed they had received training which gave them the knowledge and skills to carry out their roles. Spot checks were carried out to monitor staff practice and ensure they were working safely. People had good support with their meals. People were supported to access healthcare where needed. Staff worked very well with other professionals to ensure people’s healthcare needs were met
Staff treated people with dignity, respect, kindness and promoted their independence. Staff recorded information about people in a respectful way. Obtaining people’s views as to their end of life wishes was ongoing and information was being captured at their pace. The manager was seeking support and training for staff in order to explore with people their wishes and choices.
Systems had improved to assess, manage and monitor the oversight and quality of the service. Complaints were investigated and responded to. Where things had gone wrong, the manager was open and transparent with people, and their relatives and used their feedback to improve the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update: The last rating for this service was requires improvement (published 7 January 2020). Where we identified breaches of the regulations and made recommendations for the service to improve, the provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvement had been made and the provider was no longer in breach of the regulations.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
Follow up
We will continue to monitor information we receive about the service. If we receive any concerning information we may inspect sooner.
People’s experience of using this service:
A relative and a person told us they were happy with the care provided by Southways Group. However, standards relating to the quality and safety of the service needed to be improved. The registered provider had not always recorded areas of risk comprehensively. Staff knew how to keep people safe from harm, but the registered manager had not always raised a safeguarding concern to the appropriate bodies.
Staff had been trained in medicines, however the way the service managed people’s medicines needed to improve. Staff told us they were well supported. Staff had received some training, which included additional training relating to mental health, however, there were some core subjects that staff had not been trained in.
Care plans did not contain information about how to reduce the risk of infection and staff needed to have training in infection control. Accidents and incidents were recorded, however, the registered manager needed to introduce a system to enable them to monitor when accidents and incidents occurred.
People spoke positively about the registered manager. However, the registered manager needed to develop the governance systems to ensure they had audits and governance systems in place.
The registered manager and staff needed to develop their understanding of their responsibilities in relation to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. However, people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way.
Assessments and care plans needed to be reviewed to ensure all aspects of personal care was reflected, and that there was relevant guidance available for staff.
Staff supported people to maintain a healthy diet, in line with their assessed needs and to access health care if this was needed. People's health information was recorded. We have made a recommendation about hospital passports.
The accessible communication standard (AIS) had not been embedded into the service, we have made a recommendation about AIS.
The registered provider complaint process needed to be developed in line with current best practice guidelines. Processes were not in place to support people to plan for the end of their life. We have made a recommendation about end of life care.
Staff were kind and had developed positive relationships with people. Staff cared for people in an intuitive, empathetic and kind manner, they had a good understanding of people’s preferences.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection: This service was registered with us on 10 October 2018 and this is the first inspection.
Why we inspected: This was a planned comprehensive inspection.
Enforcement: We have identified breaches in relation to good governance.
Follow up: You can see what action we have asked the provider to take at the end of this full report.
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Whilst improvements to the service are needed, we found no evidence during this inspection that people had sustained harm. Please see the Well-Led domains sections of this full report.