# Southernwood House

*Operated by Wellbeing Residential Ltd.*

Southernwood House is a CQC-regulated home-care agency in Spalding.

## CQC Ratings

| Key question | Rating |
| --- | --- |
| Overall | Requires improvement |
| Safe | Requires improvement |
| Effective | Good |
| Caring | Good |
| Responsive | Good |
| Well-led | Requires improvement |

Rating published: 31/12/2019

## Practical info

- Postcode: PE11 2PN
- Registered manager: Huddlestone, Jacy
- Local authority: Lincolnshire
- Region: East Midlands
- City: Spalding
- Last CQC check: 26/Jul/2023 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: Recruitment processes were robust with DBS checks and references completed before employment.
  - Published: 2023-07-26
- Finding
  - Evidence: Service was working within the principles of the Mental Capacity Act with appropriate DoLS authorisations in place.
  - Published: 2023-07-26
- Finding
  - Evidence: Staff supervision frequency was increased following staff survey feedback.
  - Published: 2023-07-26
- Finding
  - Evidence: Non-medicines audits (cleanliness, falls, nutrition) were effective and driving improvements.
  - Published: 2023-07-26
- Finding
  - Evidence: Manager engaged collaboratively with health and social care professionals, including optician visits and fire safety improvements.
  - Published: 2023-07-26
- Finding
  - Evidence: Infection prevention and control measures were assured across all domains including PPE, admissions and outbreak management.
  - Published: 2023-07-26
- Finding
  - Evidence: Staff received safeguarding training and were confident in reporting and escalating concerns.
  - Published: 2023-07-26
- Finding
  - Evidence: Sufficient staffing levels maintained even below full occupancy due to increased needs post-COVID-19.
  - Published: 2023-07-26
- Finding
  - Evidence: Risks to people had been identified and care was planned to keep people safe, including appropriate equipment and staffing for moving and handling.
  - Published: 2023-07-26
- **record_keeping** _(moderate)_
  - Evidence: Fluid intake was not well recorded meaning we could not be sure people were being offered enough to drink.
  - Published: 2023-07-26
- **incident_learning** _(moderate)_
  - Evidence: There was no ongoing analysis to identify if there were any trends in the incidents. This meant opportunities to improve care could be missed.
  - Published: 2023-07-26
- **governance** _(critical)_
  - Evidence: Audits to identify issues with medicines were not effective for the last three inspections. This was a breach of regulation 17(1).
  - Published: 2023-07-26
- **medication_management** _(moderate)_
  - Evidence: Protocols were not always in place to ensure staff had the guidance needed to offer these medicines to people consistently when they needed them.
  - Published: 2023-07-26
- **medication_management** _(critical)_
  - Evidence: Medicines records did not accurately record when medicines were administered and how many were left in the home.
  - Published: 2023-07-26
- **medication_management** _(critical)_
  - Evidence: One staff member who was administering medicines had not had their competency checked within the previous 12 months.
  - Published: 2023-07-26

### safe

- Finding
  - Preventing and controlling infection
  - Published: 2023-07-26
- Finding
  - Staffing and recruitment
  - Published: 2023-07-26
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2023-07-26
- Finding
  - Assessing risk, safety monitoring and management; Learning lessons when things go wrong
  - Published: 2023-07-26
- Finding
  - Using medicines safely
  - Published: 2023-07-26
- Finding
  - Staffing and recruitment
  - Published: 2022-08-31
- Finding
  - Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrong
  - Published: 2022-08-31

### well_led

- Finding
  - Continuous learning and improving care; Working in partnership with others
  - Published: 2023-07-26
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2023-07-26
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2023-07-26
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2023-07-26
- Finding
  - Continuous learning and improving care; Working in partnership with others
  - Published: 2022-08-31
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2022-08-31
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2022-08-31
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2022-08-31

## Source

Data published by the [Care Quality Commission](https://www.cqc.org.uk/) under the Open Government Licence v3.0. Canonical page: https://homecarecompass.co.uk/agency/1-114159080

HomeCare Compass is an independent guide and is not affiliated with the CQC.