Southlands Court Residential Home

The assessment was carried out as we had continuing concerns in relation to delays in seeking medical attention when people’s health had deteriorated, and poor escalation of risks to relevant health professionals.

The provider was previously in breach of the legal regulation in relation to safe care and treatment and good governance. Improvements were found at this assessment and the provider was no longer in breach of these regulations.

The service was currently in a whole service safeguarding (WSS) process coordinated by Devon County Council due to concerns in relation to the lack of identification and escalation of people’s risks to relevant health professionals. This was the second time, in close succession, the service had been in a WSS process due to similar concerns. The last time was between February and May 2025. Southlands Court was receiving support from various health and social care professionals to improve safety in the service and their governance systems and processes. As a result of this support, improvements had been made as agreed at the follow-up WSS meeting on 13 November 2025.

Staff were increasingly adopting a proactive culture regarding health and safety incidents or concerns. Risk management had improved and staff were escalating risks to relevant professionals in a more timely way. This work needed embedding and sustaining in practice. Professionals confirmed the service were escalating risk more effectively, but felt further work was needed to maintain safe systems of care.

The provider had invested in the premises. Fire safety management had improved and protected people and others within the building. The provider undertook regular health and safety checks of the premises as part of their auditing system. Risks associated with the storage of substances hazardous to health were well managed. Safety systems and equipment used at the service were maintained and serviced at regular intervals to make sure these remained in good order and safe for use.

There were incomplete recruitment records for some members of staff, which the provider had already identified and was addressing. Staff were deployed in line with people’s assessed care and support needs. The provider was recruiting additional staff.

Medicines management practices had improved. However, further work was needed to embed the improvements in practice. There were effective infection control measures.

People had care and support plans, which required further work to ensure they were personalised, holistic, strengths-based and reflected their needs. Care and support plans were being reviewed at pace, in collaboration with people, and personalised detail was being added as part of the provider’s service improvement plan.

Daily notes and monitoring charts did not always evidence care and support plans were being followed. It was established this was a recording issue only. This was being addressed through increased monitoring by the management team and the introduction of daily checks, and reinforcement with staff of the importance of accurate clinical documentation for both safety and regulatory assurance. As a result of the additional scrutiny, compliance was improving. The provider recognised improvements needed to be sustained and embedded in practice.

On one occasion, undignified terminology was used by a member of staff. This was in relation to a description of how people were supported with their meals. We discussed this with the management team who addressed this through implementing guidance and sourcing additional training for staff.

During our first day on-site, we saw limited staff engagement with people which was meaningful. Care and support was task orientated. On our second day, this had improved and staff were engaging well with people.

The provider had recruited a care consultant to support the service in moving forward to ensure people received safe, effective and high quality care. They had also appointed a new home manager, who would be registering with the Care Quality Commission. They were due to start in post a few days after our visits to Southlands Court.

The provider was alert to any examples of a poor culture which may impact on the safety and quality of people’s care and support. They informed us they were establishing a more robust framework to ensure all performance and conduct issues were formally documented and managed in line with policies and procedures, should action needed to be taken to mitigate future risks.

Improvements had been made to how the provider assessed, monitored and improved the quality and safety of the service. Risks were increasingly being mitigated, and governance systems were identifying areas where improvements were needed. These systems and processes needed embedding and sustaining within the service.

The service improvement plan evidenced extensive work was being undertaken to ensure people received safe, effective and high quality care. This, coupled with the increased positive collaboration with health and social care professionals, including the local authority, demonstrated the provider’s goal to deliver equality of experience, outcome and quality of life for people. This work needed to continue to be sustained and embedded in practice.