Southdown Nursing Home

We undertook this assessment due to concerns raised about the quality and safety of care delivery. A full comprehensive assessment was undertaken looking at all quality statements across the 5 key questions.

Staff demonstrated kindness and attentiveness to people’s needs. We observed caring interactions throughout the visit, including staff offering reassurance, responding promptly when people requested help, and supporting people with dignity during mealtimes and personal care. Relatives provided positive accounts of the compassion and respect shown to their family members, including sensitive end‑of‑life care and regular communication from staff.

However, we also identified several areas requiring improvement to ensure people consistently experienced safe, personalised and well‑coordinated care. Environmental safety issues were significant, with concerns about unsafe window restrictors, tied-up call bells, a front door that was not always secured, and hot water being unavailable in parts of the building. Furnishings such as chairs were torn, impacting infection control.

Staffing arrangements also presented challenges. Rotas were issued at short notice, annual leave was heavily restricted, and care workers were expected to undertake laundry and activities alongside personal care duties, which created pressure and affected wellbeing. Some staff spoke positively about teamwork and training, yet others reported inconsistent managerial support and worries about speaking up. Mandatory training on autism and learning disabilities had not been completed.

Care records contained detailed assessments and risk information, but we found that documentation was sometimes difficult to navigate and not securely stored. Fluid charts lacked totals and targets, limiting their effectiveness in monitoring hydration.

Governance systems were in place, but they were not always effective in identifying and improving the quality and safety of care delivery. Information was gathered about incidents, complaints and safeguarding concerns but this information was not consistently used to inform service development and ensure continuous improvement.

Issues with environmental safety, governance, and workforce support meant improvements were required to ensure people consistently received safe, well-managed and well-led care. We found the provider in breach of regulations relating to safe care and treatment, and good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.