Southview Lodge Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. We found 2 breaches of regulation in relation to action taken in response to potential safeguarding concerns and falls, risk assessments, the environment, staff recruitment and medicines.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of safety based on openness and honesty. Whilst the service listened to concerns about safety, they did not investigate or report safety events fully, meaning lessons were not learnt to identify and embed good practice or prevent reoccurrence. People knew who to speak to about safety concerns, and staff could give examples of how they would respond to incidents and accidents. However, several people had suffered repeated falls; and action had not been taken to analyse patterns, refer to healthcare partners or notify the appropriate agencies. In response to feedback, the provider sought guidance to improve their knowledge and understanding of notifiable incidents, and implemented new systems to review and act upon safety events.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.  People and relatives confirmed the referral and transition process was efficient and spoke about the service helping to organise emergency placements when support at their family home had broken down. One relative told us, “They were ever so helpful, so kind, they bent over backwards for us.” Information was gathered about people before moving into the service and staff told us they received verbal handovers, to aid their understanding of people’s needs and preferences prior to delivering support.

The service did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on protecting people’s right to live in safety, free from avoidable harm; or share concerns quickly and appropriately. Processes for monitoring and reporting concerns were not robust. Local authority guidance had not been checked following potential safeguarding incidents, and there was no safeguarding log to prompt or record actions. However, people and relatives raised no concerns of abuse or neglect and staff we spoke to had a good understanding of safeguarding. Following our visit, the provider took action to improve safeguarding processes.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them. During our assessment staff were observed to help people move around the service safely and offer prompts to people to drink more, to prevent risk of dehydration. A person using the service said, “Staff help me understand my risks, I understand I can’t get up without help in case I fall.” However, information about risks to people noted in care plans or risk assessments was not always accurate or consistent, so we could not be assured care met people’s needs safely. The registered manager has since organised a review of people’s information to ensure it is correct.

The service did not always detect and control potential risks in the care environment, or make sure equipment or facilities supported the delivery of safe care. For example: we observed taps running at a high temperature, uneven flooring and incorrect pressure mattress settings meaning people were at risk of scalds, falls or pressure injuries. Several safety checks were not regularly completed as per best practice guidance, including checks to water temperatures, bed-rails and mattresses. In response to feedback, the provider reviewed guidance, implemented additional checks and improved oversight of premises and equipment. Works have been scheduled to address concerns raised around safety at the service.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. A relative told us, “The home seems quite well staffed, there’s always plenty of staff about,” and staff confirmed they received enough training and felt well supported by leaders. However, the service did not always follow legislation or their own policies around safe recruitment. A number of staff did not have 2 references and there were several gaps to application forms, interview notes, identification and DBS checks. Disclosure and Barring Service (DBS) checks provide information including details of convictions and cautions held on the Police National Computer. The information should help employers make safer recruitment decisions. Since our assessment, the provider has taken action to audit recruitment files, draft risk assessments and seek missing documentation.

The service did not always assess or manage the risk of infection, and did not always detect and control the risk of it spreading. Processes to reduce the risk of legionella were not robust. However, the service was observed to be clean and tidy, personal protective equipment (PPE) was available for staff, and systems to manage infection prevention and control (IPC) were in place. People were supported to maintain a good level of personal hygiene. A relative told us, “[Person] seems very well looked after, they have regular baths, and their hair and nails are always done.”

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Room and fridge temperature checks were not carried out in line with best practice guidance, meaning medicines could have become unknowingly spoiled or ineffective. Several discrepancies with medicines counts were identified and MARs evidenced gaps to topical creams and eye drops, meaning we were not assured people received their medicines as prescribed. Following feedback, the registered manager ensured a full audit of medicines was carried out and planned to implement new recording systems for topical creams. Staff confirmed they had appropriate training and were observed to administer medicines safely and efficiently. The registered manager spoke about the service’s new electronic medicines system, aimed at reducing errors and improving oversight.