The unannounced inspection took place on 01 March 2016. We had previously carried out an inspection in November 2013 when we found the service was meeting all the regulations reviewed at that time.Southlands Residential Home is a large detached property, registered to provide accommodation for up to 27 people. This is provided in either single or shared rooms. The home has large, well maintained gardens and a large car park for visitors. It is situated close to local amenities and bus routes into Bolton. At the time of the inspection there were 22 people residing at the home.
There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. On the day of the inspection the registered manager was unavailable. However, the administration manager and the care manager facilitated the inspection.
We found a breach of the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014. This breach related to staff support. You can see what action we told the provider to take at the back of the full version of the report.
We looked at rotas and saw that staffing levels were good. Staff we spoke with confirmed this. We saw that there was a robust recruitment procedure, which helped ensure employees were suitable to work with vulnerable people.
Appropriate risk assessments were held in care files. The environment and equipment were maintained and checked regularly.
Staff had undertaken training in safeguarding adults and were aware of the procedures to follow if they had a concern. Staff had also undertaken appropriate medication training and safe systems were in place for the ordering, dispensing, storage and disposal of medicines.
We observed the lunchtime meal and saw that the food was of a good standard and people’s nutritional needs and requirements were catered for. Monitoring charts were completed to ensure people’s health and well-being was being overseen.
Care plans included a range of health and personal information and were regularly reviewed and updated.
Staff had undertaken a robust induction programme on commencement of their employment and training was on-going within the service.
The service was working within the legal requirements of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS).
People told us staff were kind and caring. We observed interactions between staff and people who used the service and saw that they were friendly and courteous. People’s privacy and dignity was respected.
Information was given to people who used the service and their relatives and communication was good.
A number of staff had undertaken training in end of life care and people’s wishes for the end of their life were documented.
People’s choices with regard to times to get up and go to bed, the clothes they wished to wear, what food they wanted and how they wanted to pass the day were respected. These choices and preferences were recorded within the care files.
There was a range of activities on offer at the home and people were encouraged to follow their own hobbies and interests.
There was an appropriate complaints policy but there had been no recent complaints. We saw a number of compliments received recently by the home.
People who used the service, relatives and staff said the management were approachable at all times.
Policies and procedures were in need of updating and some contact details were out of date.
Staff supervisions and appraisals had not been undertaken for some time and staff meetings had not been held for a significant length of time, though one was arranged for the near future.
There were a number of audits and checks in place but monitoring and analysis of matters such as accidents and incidents was not undertaken.
The service linked in with local meetings to help ensure they were aware of current good practice guidelines.