Best At Home (Southerton House) improved from Requires Improvement to Good following a focused inspection of Safe and Well-Led domains, demonstrating sufficient remediation of previous regulatory breaches around staffing coordination, medicines management, and incident notification. The provider introduced robust electronic monitoring systems, a dedicated compliance manager, and strengthened governance processes, with people and relatives reporting consistently safe, person-centred care.
Strengths
· Electronic call monitoring (ECM) system effectively used to coordinate and monitor staff visit times, auto-alerting managers to late, early or missed calls
· No recording errors or omissions found on electronic medicines records; medicines regularly audited by managers and staff
· Thorough staff recruitment processes including DBS checks, identity, right-to-work, and character references consistently followed
· New quality assurance and compliance manager role created to oversee governance systems and drive continuous improvement
· Person-centred, up-to-date care plans with detailed risk assessments reviewed and updated as needs changed
Focused inspection downgraded Safe and Well-led from Good to Requires Improvement, with a breach of Regulation 18 (Staffing) after ECM data showed thousands of late or shortened visits. Medicines audits, MAR legibility and notification of incidents to CQC were also flagged, though safeguarding, risk management and leadership culture remained positive.
Concerns (6)
criticalStaffing levels: “The registered manager failed to ensure sufficient numbers of staff were deployed to keep people safe.”
criticalMissed or late visits: “2411 calls were more than 45 minutes late. We also identified for 12642 calls; staff stayed less than half of the planned time.”
moderateMissed or late visits: “They are meant to stay for half an hour, but they stay for around 10 minutes. Mostly there are two staff, sometimes there is only one”
moderateGovernance: “we found medicines audits were not always contemporaneous; in that we saw the same findings were recorded over several months.”
moderateGovernance: “the registered manager had not informed us of two incidents which required reporting to the regulatory body.”
minorRecord keeping: “We checked the completed MAR and found these were completed accurately however were, on occasion, messy and illegible.”
Strengths
· Robust pre-employment checks including DBS, references and identification verification
· People continued to be safeguarded against the risk of abuse with ongoing staff safeguarding training
· Risk assessments were regularly reviewed and gave staff clear guidance to mitigate risks
· People received their medicines safely and as prescribed
· Service worked within the principles of the Mental Capacity Act
Quality-Statement breakdown (10)
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
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: Continuous learning and improving careGood
well-led: Working in partnership with others and duty of candourGood