Southlands Place

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 71 (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 had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff told us the management team were approachable, supportive and promoted an inclusive work environment. The registered manager told us she operated an open-door policy and ensured that the management team spent time on the floor meeting people and staff. Not all people could tell us that knew the registered manager, but we observed throughout the site visits that they greeted her and obviously knew her. The registered manager had a good knowledge of all the staff and knew their strengths and weaknesses. Staff told us that the management team were approachable and were confident that they would be listened to. One staff member said, “I can take anything to them and I feel supported.” There were systems and processes in place to support staff development and progression within their roles. Staff talked of how they were supported to gain qualifications and extend their role, for example, becoming medicine givers and champions. We saw evidence that staff received regular supervisions, spot checks, competencies and values-based supervisions. The provider’s senior management team visited the home regularly and provided support and supervision to the registered manager. The registered manager told us she attended organisational manager meetings which enabled learning across the organisation to be shared and relevant lessons learnt implemented within the home. The provider supported the registered manager and staff to attend external training and meet with other providers and managers to network through various forums.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were confident to speak up about concerns and they had numerous opportunities to speak up if needed, at handovers, team meetings and supervision. Staff were aware of the whistle blowing policy but felt that they could raise issues and be listened to. One staff member said, “I wouldn’t hesitate to raise concerns, we can do it anonymously if we wished to, but I haven’t had to.” The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance. The provider and registered manager understood their responsibilities under the duty of candour. The Duty of Candour is to be open and honest when untoward events occur. We have received statutory notifications regarding as required, however the provider has acknowledged that there has been delays in the submission of approved DoLS and this was being rectified. During our assessment we found that the management team were open and transparent. They admitted when things had gone wrong and demonstrated how they had used these to make improvements. People and their relatives confirmed they knew how to complain, and a copy of the complaints policy was available in the service and on the service website. Relatives told us they would talk to staff and the manager and if not dealt with would do it formerly. A record of complaints was held in the service. These included the information on the complaint and how this was responded to. We saw complaints had been responded to and actions taken as necessary.

There were organisational quality assurance and governance systems which were used to improve, sustain and consistently develop the service. However, we found some areas regarding medicine administration charts that needed to be improved, not all behavioural charts were completed in full following administration of PRN medicines. Some documentation in relation to water temperatures were not clearly dated and this was resolved immediately with new forms requested. This meant that the systems in place were not fully effectively. The management team worked well as a team to ensure there was oversight and effective governance at the service. There were computerised systems and processes to assess, monitor and improve the quality and safety of the service provided. This included health and safety, accidents, incidents, complaints, medication management and staff documentation. Staff were knowledgeable and could tell us of safeguards put in place to mitigate risk, such as risk reduction, low level beds and sensor mats. The management team demonstrated a proactive response to any areas of improvement highlighted and valued all feedback to ensure that there was a culture of openness to facilitate ongoing learning. For example, following up immediately regarding some queries in respect of PRN mood stabilisers and introducing guidance for staff in respect of oral health for those that live with dementia. The leadership team engaged with local partners to ensure that they were kept up to date on best practice. One health care professional said, “Pretty good at contacting us.” The manager demonstrated a good understanding of the regulatory requirements. Staff understood their role and responsibilities. They all had job descriptions, contracts and received support from the management team to ensure they had the necessary training.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. Not everyone was able to share their experiences, but those that could told us, "I love the activities, we have quizzes, we meet our friends, Christmas was very lovely,” and “I see different doctors and nurses, I also see a chiropodist and optician.” Relatives told us, "The activities are very good here, always something going on, lots of Christmas events, which everybody was involved in,” and "The home really makes a fantastic effort with special occasions, such as birthdays and other special dates.” We were also told by relatives that their loved ones had appropriate referrals to other health and social care professionals when required. One relative said, “Very good choices and activities.” The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partner agencies and collaborate for improvement. Staff built relationships with community groups. The registered manager told us how they worked with other healthcare professionals to ensure continuity of care. Health and social care professionals visited the home regularly and were able to assess people following their admission to the home from hospital or home. Staff had access to the tissue viability team, falls team, dieticians and other specialist services as necessary. Staff told us of how they monitored people and used risk assessments to ensure they requested referrals in a timely way.