CQC report explained · a nursing home
What the CQC found at Alt Park Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2023
Rated Requires Improvement; the home had improved since being Inadequate and in special measures, but inspectors found unsafe medicines and weak care records.
Inspectors visited without notice on 5 and 10 October 2023. They spoke with people living at the home, relatives and staff. They observed care, checked the building and reviewed care plans, medicines, staffing, safety records and quality checks.
There had been improvements since the previous inspection. The home was clean and in better repair. Infection control, staffing, safeguarding, consent arrangements and people's access to food and healthcare had improved. People and relatives also spoke positively about staff being kind and caring.
However, inspectors found that medicines were not always managed safely. Some risk assessments and care plans were incomplete, inaccurate or confusing. Records about incidents, complaints and quality checks were not reliable enough to show that problems had been fully addressed.
The overall rating and all five question ratings are Requires Improvement. The home had previously been rated Inadequate and was in special measures. It is no longer in special measures, but the provider remains in breach of regulations and must send an action plan.
Kind and respectful staff
People, relatives and inspectors described staff as kind, compassionate and respectful. Inspectors saw staff protect people's privacy and dignity.
“We observed staff knocking on people's doors, speaking to them with respect and compassion.” from the report
Cleaner, improved environment
The home was clean, tidy and in better repair. Communal areas had been redecorated, and a maintenance person was working through an improvement plan.
“The environment had improved and the home was clean, tidy and in a good state of repair.” from the report
Improved infection control
Staff followed infection prevention practices and had completed infection control training. The home was no longer in breach in this area.
“People were protected from the risk of infection as staff were following safe infection prevention and control practices.” from the report
Improved consent arrangements
The provider had improved its work under the Mental Capacity Act. Capacity assessments were in place where needed, and staff had received relevant training.
“The provider was working in line with the Mental Capacity Act.” from the report
Food and activities
People had varied food choices, including modified diets, and said they liked the meals. An activities coordinator supported people with games and conversation.
“There was varied choices available for people at mealtimes and special and modified diets were catered for.” from the report
Medicines were not always safe
seriousMedicine quantities did not always match the records. Guidance for medicines given when needed was sometimes missing, and some medicines were not given at the correct time.
“The remaining quantities of medicines did not always reconcile with the records of medicines given therefore, we were not assured people had their medicines as prescribed.” from the report
Risk and care plans lacked detail
seriousSome assessments contained conflicting information or did not explain how to manage risks such as choking. Care plans did not always say how often checks or repositioning should happen.
“Some risk assessments had been re-written and had improved with regards to mitigation and clinical information, however, we saw for some people this required further improvement.” from the report
Quality checks missed problems
seriousAudits did not consistently identify problems with care plans, medicines, incidents, pressure sores or complaints. Some actions were not followed up to check they had been completed.
“Medication audits had not highlighted or addressed some of the concerns we found with regard to medicines.” from the report
Complaint records were incomplete
needs fixingComplaints were responded to, but there was no tracking process. This made it difficult to see the progress of a complaint or whether changes had improved care.
“However, there was no process in place to track complaints.” from the report
Mattress checks were missing initially
needs fixingMattress checks were not in place on the first inspection day, and one air-flow mattress was switched off. The provider put checks in place before inspectors returned on day two.
“On day 1 of our inspection mattress checks were not in place, and we observed 1 person's air flow mattress was switched off.” from the report
- 01How are medicines now checked so records match the quantities given, and are medicines given at the correct times?
- 02How do you make sure each person's risk assessment and care plan is accurate, consistent and clear for staff?
- 03How often are repositioning and clinical observations required for my relative, and how do you check that records are completed?
- 04How are complaints recorded and tracked from receipt through to the final response and any improvement?
- 05Who is currently responsible for the home while the manager's registration is being processed, and what progress has been made since the inspection?
This was an unannounced inspection to check whether the provider had acted on breaches found at the previous inspection, and inspectors reviewed all five key questions. This explanation was written from the published report of 24 November 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2023
Rated Inadequate and placed in special measures; inspectors found serious risks in safety, care, dignity and management.
This was an unannounced inspection over three visits in March 2023. Inspectors spoke with people, relatives and staff, observed care and activities, checked the building and reviewed care, medicine, recruitment, safeguarding and quality records.
Inspectors found widespread and significant problems. Risks were not properly assessed, medicines were not managed safely, infection control was inconsistent and some staff recruitment checks were missing. Care records were incomplete and did not give staff enough guidance. People’s privacy, dignity, choices and involvement in care were not always respected.
All five areas were rated Inadequate: Safe, Effective, Caring, Responsive and Well-led. The home was previously rated Good in September 2021. Immediate actions were taken during the inspection, but CQC said it was not yet assured that these changes were effective or firmly in place.
Immediate response
The senior management team took immediate steps during the inspection to reduce the risks identified. An interim manager was also appointed at the end of the inspection.
“During the inspection the senior management team and nominated individual ensured immediate actions were taken to mitigate the failures highlighted in this report.” from the report
Access to healthcare
The home had arrangements for people to receive support from GPs and other health professionals who visited regularly.
“GP services and associated health care professionals visited the service on a regular basis to monitor people's health.” from the report
Visits
The home was facilitating visits for people living there in line with the guidance in place at the time.
“The provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
Choice and least restriction
The report found that the home’s policies and systems supported people to have choice and control and to be supported in the least restrictive way possible.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Unsafe medicines
seriousCovert medicines were not always given safely or on time. Staff competency checks, as-required medicine guidance and patch records were also not adequate.
“Unsafe medication practices were observed for people who required covert medicines (hidden in food or drink).” from the report
Poor risk management
seriousRisk assessments and care plans were incomplete or inaccurate. Accidents and incidents were not analysed well enough to reduce the chance of them happening again.
“People's risks had not been adequately assessed and mitigated.” from the report
Safeguarding failures
seriousSome safeguarding incidents were not properly investigated, including repeated incidents involving people entering bedrooms and hitting others. Staff were not all clear about how to raise concerns.
“People were not protected from the risk of abuse because processes were not always followed.” from the report
Unsafe environment
seriousThe building had trip hazards, damaged areas and poor decoration. Emergency evacuation information was incomplete, and some bathrooms did not provide privacy.
“There were health and safety hazards throughout the service that had not been identified or actioned by the provider in a timely manner.” from the report
Incomplete care planning
seriousRecords did not consistently describe people’s health, emotional, spiritual, cultural or communication needs. Staff therefore lacked clear guidance about how to provide individual care.
“Staff did not have access to robust care plans which were needed to support people effectively.” from the report
Weak leadership and oversight
seriousAudits did not lead to timely action, records were incomplete and staff deployment meant some people waited longer for call bells to be answered. The home did not have a registered manager in post at the inspection.
“The governance and leadership within the service was ineffective.” from the report
- 01What specific changes have been made to medicine checks, covert medicines, as-required medicines and staff competency assessments?
- 02How are you now recording and reviewing accidents, incidents and safeguarding concerns, and how do you show that lessons have been acted on?
- 03Have all residents’ care plans and risk assessments been reviewed to include their health needs, preferences, communication needs and end-of-life wishes?
- 04What repairs have been completed to remove trip hazards, improve bathrooms and bedrooms, and make emergency evacuation information accurate?
- 05What management and staffing changes have been made since the inspection, and how are you checking that improvements are lasting?
This started as a focused inspection of Safe and Well-led after concerns were received, but further risks meant CQC also reviewed Effective, Caring and Responsive; all five ratings were given. This explanation was written from the published report of 23 June 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Alt Park Nursing Home
9 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- November 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2023Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- September 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2020Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2018Requires improvementstayed Requires improvementEffective: Requires improvementWell-led: Requires improvement
- December 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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