Southways Group Ltd, a first-time inspected supported-living homecare provider for five people with complex needs, was rated Requires Improvement across all five key questions following its December 2019 inspection. A breach of Regulation 17 (Good Governance) was identified due to absent auditing systems, unrecorded spot checks, and gaps in safeguarding, medicines management, care planning, infection control, and Mental Capacity Act compliance, despite staff demonstrating genuine kindness and person-centred values.
Concerns (13)
criticalSafeguarding: “there had been one allegation of abuse, the registered manager had carried out an investigation, but had not raised this concern with the appropriate body.”
criticalGovernance: “Record-keeping was not holistic and comprehensive, and there was a lack of robust systems and processes to assure the quality of service people received. This was a breach of regulation 17.”
moderateMedication management: “Where people were prescribed, as required medicine, protocols were not in place regarding their use. Staff had been trained in medicines, but competency assessments were not carried out.”
moderateCare planning: “Care plans lacked information explaining how they supported people in relation to personal care. Care plans did not contain a copy of peoples' financial profiles.”
moderateInfection control: “Staff had not been given infection control training. Care plans did not contain information about how to reduce the risk of infection.”
moderateStaff training: “Additional training needed to be provided relating to infection control, diabetes, epilepsy, manual handling, and oral healthcare, equality and diversity.”
moderateConsent / capacity: “Staff was not routinely trained in the MCA and DoLS. The registered manager and staff needed to develop their understanding of the requirements of the Mental Capacity Act 2005.”
moderateRecord keeping: “The registered manager told us they carried out audits but had not recorded what key areas of the service they had audited. 'I dip in and out of the service, but I don't record the checks I do.'”
moderateIncident learning: “The registered manager needed to introduce a system to enable them to monitor when accidents and incidents had occurred. There was limited use of systems to record when safety concerns had been discussed.”
minorComplaints handling: “The complaints policy was available but needed to be developed to meet current best practice guidelines. The policy did not provide information about how people could raise or escalate any complaints.”
minorCommunication with families: “People were not asked for their views, and if they were, they weren't recorded, so this information couldn't be used to ensure that people received a service they were satisfied with.”
minorEnd-of-life care: “Policies and procedures relating to end of life care were not in place.”
minorPerson-centred care: “People's care plans did not consider how information and communication needs could be met. People's communication needs were not identified, recorded, and highlighted in care plans.”
Strengths
· Staff were kind, empathetic and had developed positive relationships with people, intuitively working effectively with those they supported.
· Regular supervision and annual appraisals were carried out, with staff reporting they felt well supported.
· Staffing levels were consistent with several long-serving staff, and rotas organised to provide people with a consistent team.
· People were supported to access the community, attend courses, and participate in activities promoting independence and mental wellbeing.
· People's healthcare needs were monitored with access to GPs and specialist services such as dentists and opticians.
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Learning lessons when things go wrongRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to live healthier lives, access healthcare services and supportRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Ensuring people are well treated and supported; equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Supporting people to develop and maintain relationships to avoid social isolationRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Continuous learning and improving care; engaging and involving people using the serviceRequires improvement
well-led: Planning and promoting person-centred, high-quality care and support; duty of candourRequires improvement
Southways Group Ltd improved from Requires Improvement to Good across all five key questions following a follow-up inspection in May 2021, having addressed previous breaches including safeguarding, medicines management, care planning, staff training and governance. Minor gaps remained around end of life care training for staff and the recording of people's full protected characteristics, both of which the manager committed to addressing.
Concerns (2)
minorEnd-of-life care: “Staff had not received any training in end of life care. They told us discussing these subjects can be very difficult for people and staff.”
minorCultural competency: “we saw only people's religion had been recorded. People's age, disability, ethnicity, sexual orientation and gender were part of who they were.”
Strengths
· Significant improvements made across all five key questions since the previous Requires Improvement rating in January 2020
· Robust safeguarding processes in place with staff trained and alerts raised to relevant bodies appropriately
· New medicines management policy introduced in line with NICE guidance with regular audits and computerised MAR sheets
· Consistent staff team with rotas published a month in advance, ensuring people saw the same staff and relationships were maintained
· Governance and performance management systems implemented including computerised quality audits, financial checks and accident/incident monitoring
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and 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