29 June 2023
During an inspection looking at part of the service
Southdowns Nursing Home provides accommodation, personal and nursing care for up to 50 people living with physical frailty, sensory impairment, dementia, and mental health problems. There were 46 people living at the home at the time of our inspection. Accommodation is arranged over 2 floors and each person had their own bedroom. Access to each floor is gained by a lift, making all areas of the home accessible to people.
People’s experience of using this service and what we found
The governance systems in place did not support the service to consistently improve and sustain safe care delivery. Audit systems and processes failed to identify risks to people's safety. There was a lack of clear and accurate records regarding some people's care and support. For example, people who lived with emotional distress and how staff manage their needs safely.
Communication methods used between staff were not always used effectively to inform staff of changes to people’s care. Care records were missing vital points for staff to follow up on, such as recent incidents, bruising noted or who was not receptive to personal care. Changes to people’s health and well- being were therefore not always planned for and monitored effectively.
Whilst staff numbers were appropriate and based on peoples’ dependency needs, the deployment of staff had the potential to impact on peoples’ safety. For example, lack of supervision in communal areas.
People received care and support from staff who were appropriately recruited and trained to recognise signs of abuse or risk and understood what to do to safely support people. People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible.
Referrals were made appropriately to outside agencies when required. For example, GPs, community nurses and speech and language therapists (SALT). Notifications had been completed to inform CQC and other outside organisations when events occurred.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 31 December 2019).
Why we inspected
We received concerns in relation to staffing, risk management and care delivery. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see safe and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Southdowns Nursing Home on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to safe care and treatment and good governance.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.