CQC publishes another damning report into failing Southfield Care Home

The Care Quality Commission (CQC) visited Southfield Care Home in Great Horton in March.

The home was rated as ‘inadequate’ and plunged into special measures in January last year and inspectors have made additional visits since then. 

Following the latest inspection, a report highlighted a worrying catalogue of problems.

It said: “Despite highlighting shortfalls at the last three inspections, the provider had failed to take enough action and people continued to be at risk of harm and poor care.”

One person had even been harmed while the inspection was taking place, the report said.

Inspectors said procedures “failed to safeguard people from the risk of abuse”. 

The report said: “During the inspection, a safeguarding event had taken place between two people living at the home which resulted in one person sustaining harm. 

“We spoke with four staff and found they were not aware of the incident. On the second day of the inspection we reviewed the person’s risk assessments and no updates had been made to reflect what had happened.

“Other records showed potential incidents of abuse had happened which had not been referred to the relevant authorities. 

“For example, there were two recorded incidents where different people had been hit by other people living at the home. This meant there was no monitoring or oversight from external bodies. 

“We identified reports of service users having injuries when the cause was unknown. There was no evidence of a follow-up investigation or a referral to the relevant safeguarding authority. 

“Unexplained injuries were not investigated to establish if there were signs of abuse. This meant we were not assured service users were protected from the risk of injury or harm from abuse. We have made referrals to the local safeguarding authority.”

Inspectors said issues raised in the latest visit had been identified at previous inspections but “lessons had not been learned and action had not been taken”. 

The report said assessments did provide clear and up-to-date information. 

It said: “For example, records showed that one person had recently pushed and hit people, pulled hair and thrown items. Their risk assessment stated the person was aggressive and known to attack people. 

“There were no further details recorded or guidance to staff about how to support the person consistently.”

The report said building checks were “not robust” and maintenance issues were not followed up promptly. 

It added: “Accidents and incidents were recorded, but the information was often not fully completed and provided a limited overview of what had happened. 

“There was a lack of information about what action had been taken to prevent a re-occurrence. For example, one person had recently fallen out of bed. Their risk assessments had been reviewed since the incident, but the fall risk was not considered and there were no changes made to prevent a re-occurrence.”

Concerns were also raised about staff recruitment.

“The required employment checks to ensure individuals were suitable to work with people had not been completed,” said the report.“We requested staff recruitment records after the inspection. We did not receive these. We were not assured staff were recruited safely.”

The CQC said “significant shortfalls” were found at the last three inspections and it found “continued breaches of regulations relating to medicines, the management of risk, safeguarding and good governance”. 

A spokesman for the home said: “The whole staff at Southfield is disappointed with the outcome of the report. The care home has a very dedicated, highly trained and very motivated staff. A new manager has been appointed at the beginning of the year, along with a new consultant who is an ex CQC inspector.”

He said he did not feel there was enough time between an inspection in November last year and the most recent visit and it did not give staff an opportunity to put in place “the appropriate policies and procedures”.

The spokesman said it is the first time in the care home’s history that it has had issues with performance, and this was mainly due to four managers leaving the service in the past 14 months, without giving notice.

He said the settled team now in place would turn the care home by the next inspection and added: “As long as we are judged objectively.”