Southernwood House received a third consecutive 'Requires Improvement' rating, with breaches of Regulations 12 and 17 persisting due to unsafe medicines management and ineffective medicines audits. Despite these ongoing failings, staffing, safeguarding, infection control, and overall home culture were found to be positive.
Concerns (6)
criticalMedication management: “One staff member who was administering medicines had not had their competency checked within the previous 12 months.”
criticalMedication management: “Medicines records did not accurately record when medicines were administered and how many were left in the home.”
critical
Governance
: “Audits to identify issues with medicines were not effective for the last three inspections. This was a breach of regulation 17(1).”
moderateMedication management: “Protocols were not always in place to ensure staff had the guidance needed to offer these medicines to people consistently when they needed them.”
moderateIncident learning: “There was no ongoing analysis to identify if there were any trends in the incidents. This meant opportunities to improve care could be missed.”
moderateRecord keeping: “Fluid intake was not well recorded meaning we could not be sure people were being offered enough to drink.”
Strengths
· Risks to people had been identified and care was planned to keep people safe, including appropriate equipment and staffing for moving and handling.
· Sufficient staffing levels maintained even below full occupancy due to increased needs post-COVID-19.
· Staff received safeguarding training and were confident in reporting and escalating concerns.
· Infection prevention and control measures were assured across all domains including PPE, admissions and outbreak management.
· Manager engaged collaboratively with health and social care professionals, including optician visits and fire safety improvements.
Quality-Statement breakdown (9)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; Working in partnership with othersGood
Southernwood House remained rated Requires Improvement following a focused inspection of Safe and Well-led, with a continued breach of Regulation 12 due to unsafe medicines recording, infection control lapses and incomplete risk planning for domiciliary care users. Improvements had been made in safeguarding, MCA/DoLS compliance and governance audits, though audits still missed some areas of best practice.
Concerns (7)
criticalMedication management: “Medicines were not always accurately recorded or regularly checked, to show people received their medicines when they should. Mistakes in the recording of medicines had not been identified or investigated.”
criticalInfection control: “Some areas of the home were not clean... some beds which had been made, had dirty bedsheets. High level cleaning was inconsistent and there were cobwebs in places. Toilet brushes were not clean”
moderateCare planning: “the care plans for people who received care in their own home lacked personalised information on risks to keep them safe.”
moderateStaff training: “Moving and handling training had not been completed and staff's abilities to move people safely had not been assessed.”
moderateGovernance: “some audits did fall short in identifying some of the concerns we found. This was because they had not included all areas of best practice within each audit.”
moderateRecord keeping: “one person's medicine records showed that they had one more of dose a controlled medicine in stock than was in the cupboard due to an error being made when transferring figures to a new page.”
minorIncident learning: “analysis of incidents over time was missing and so the registered manager may miss opportunities to improve the care provided.”
Strengths
· Enough staff to meet people's needs and safe recruitment processes including DBS checks were followed.
· Staff had received training in safeguarding and were confident to raise concerns.
· Service was working within the principles of the Mental Capacity Act with appropriate DoLS authorisations in place.
· Registered manager worked collaboratively with the local safeguarding authority and health/social care professionals.
· Provider was working in line with government guidance regarding unrestricted visiting and PPE was used effectively.
Quality-Statement breakdown (7)
safe: Assessing risk, safety monitoring and management; Preventing and controlling infection; Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; Working in partnership with othersRequires improvement