Southlands Retirement Apartments with Care and Support (Westward Care Limited) received an overall Good rating at its December 2023 inspection, with Safe and Well-led both rated Good. Key weaknesses included an outdated medicines policy unsuited to extra-care housing, gaps in medicines auditing since March 2023, and inconsistencies in governance audits, resulting in three recommendations but no regulatory breaches.
Concerns (4)
moderateMedication management: “The services medicines policy did not reflect the service provided, this meant that staff did not have a framework for safe medicines management.”
moderateMedication management: “Medicines audits of daily administration had been completed however audits on wider medicines management had not been completed since March 2023.”
moderate
Governance
: “Regular audits of the quality and safety of the service did not always take place as required. When these did take place there was occasional inconsistencies and gaps in records.”
minorCommunication with families: “One person felt that the management were not as proactive as they would like and felt that they had signed up to a different package to what was being delivered.”
Strengths
· People felt safe and provided positive feedback about the care received, with one stating 'I can't see room for improvement, it is an excellent service.'
· Risks to people's care were well managed with assessments and actions in place; incidents were analysed and learning applied.
· Safe recruitment practices were followed and a regular staff team provided consistent, person-centred support.
· Infection control was well managed with clean communal environments and staff trained in infection prevention.
· Staff felt well supported by management and described an open, approachable leadership culture.
Quality-Statement breakdown (9)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
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, understanding quality performance, risks and regulatory requirementsGood
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