CQC report explained · a nursing home
What the CQC found at Grove Park
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found kind, responsive care but important safety, staffing and management problems.
Inspectors visited on 1 February 2023. They toured both wards, spoke with patients, a carer, managers and staff, and reviewed care records, medicines records, staff files and other documents. This report covers the hospital part of the service, not the nursing home part.
The wards were clean and pleasant. Patients said staff treated them well and that they felt safe. Medicines were managed safely, safeguarding procedures were followed, and staff understood their Mental Health Act duties. Care was rated Good for caring and responsiveness.
The overall rating was Requires Improvement. Inspectors found risks that had not been fully assessed, restrictions on patients making hot drinks and snacks, gaps in physical health monitoring, high staff vacancy rates, a lack of occupational therapy, and poor involvement of patients in care planning. Management checks and records did not always identify or act on problems.
Clean and pleasant wards
The wards were clean, maintained and described as pleasant. Cleaning records were up to date and infection control procedures were followed.
“The wards were very pleasant and nicely decorated.” from the report
Kind staff
Patients told inspectors that staff treated them well and behaved kindly. Inspectors found staff respectful, compassionate and aware of patients' individual needs.
“Patients said staff treated them well and behaved kindly.” from the report
Safe medicines arrangements
Inspectors found that medicines were prescribed, stored, administered and recorded safely. Staff also reviewed their effects on patients' mental and physical health.
“The service used systems and processes to safely prescribe, administer, record and store medicines.” from the report
Support for staff
Managers provided induction, training and regular supervision. Supervision had improved since the previous inspection.
“Supervision rates had improved since the previous inspection, with 100% of staff receiving supervision over the last 2 months.” from the report
Unassessed ligature risks
seriousOne ward did not have a ligature risk assessment or documented measures to reduce the risks. Inspectors said this exposed patients to avoidable harm.
“There was no ligature risk assessment on Saunderson ward.” from the report
Patients not involved in care plans
seriousPatients told inspectors they had not been involved in planning their care. The care plans reviewed did not show that patients had signed them or been offered copies.
“All of the patients we spoke with told us they had not been involved in their care planning.” from the report
High staff vacancies
needs fixingThe service relied on bank and agency staff while trying to recruit. Vacancy rates were 37% for nurses and 45% for healthcare assistants.
“The service had a 37% vacancy rate for nurses and a 45% vacancy rate for healthcare assistants.” from the report
Weak management checks
seriousThe risk register had not been updated since September 2022. Audits identified some problems but did not always record what would be done, and complaint learning was not documented.
“The provider had a risk register in place but this was not kept up to date.” from the report
Restrictions on hot drinks and snacks
seriousPatients could not make hot drinks or get snacks without staff support because kitchen facilities were separated from the main ward areas. The provider started work to add facilities on the wards after the inspection.
“Patients were dependent on staff to access snacks and hot drinks.” from the report
- 01Has the full ligature risk assessment been completed on every ward, and what measures are now in place?
- 02What are the current nurse and healthcare assistant vacancy rates, and how often are bank or agency staff being used?
- 03How do you now make sure each patient is involved in their care plan and receives a copy?
- 04How are physical health checks, capacity assessments and consent discussions recorded and audited?
- 05What changes have been made so that audits and complaints lead to clear action and learning?
This inspection rated the hospital's two acute mental health wards across all five key questions; the nursing home part of Grove Park was covered in a separate report. This explanation was written from the published report of 13 April 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, March 2023
Rated Good; inspectors found safe, kind and personalised care, with improvements made since the previous inspection.
This was an unannounced follow-up inspection on 1 February 2023. Inspectors looked at the two nursing units, where 43 people were living. They spoke with people, relatives and staff, observed care and checked records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable care plans and good infection control. People said they felt safe and were treated kindly.
The provider had fixed problems found at the previous inspection. These included gaps in food and fluid records, staff training and supervision, and quality monitoring. The home was no longer in breach of the regulations mentioned in the earlier report.
Hydration and risk records
The home had introduced electronic care planning, with fluid intake recorded in real time and reviewed by the manager.
“We saw that fluid intakes were recorded as they happened, and staff had access to information to guide them on the amount of fluids to offer people.” from the report
Kind and respectful care
Inspectors saw positive relationships between people and staff. People were offered choices and supported to keep their privacy, dignity and independence.
“People were happy with the care they received, felt relaxed with staff and told us they were treated with kindness.” from the report
Personalised support
Care plans included people's preferences, personal histories, religious beliefs and interests. Staff were said to know people well.
“Individual person-centred care plans had been developed, enabling staff to support people in a personalised way that was specific to their needs and preferences, including any individual religious beliefs.” from the report
Activities and family contact
There was a range of activities, including music, arts and crafts, quizzes, exercise and visits from entertainers. Staff also arranged one-to-one activities for people who stayed in their rooms.
“There was a range of activities on offer which included, music, arts and crafts, quizzes, exercise, Tai-Chi and visits from external entertainers.” from the report
Improved management systems
The manager had introduced audits covering areas such as medicines, infection control, care planning and health and safety. Staff reported feeling supported.
“The manager undertook a range of quality assurance audits to ensure a good level of quality was maintained.” from the report
Manager registration
minorThere was no registered manager in post when inspectors visited. The service manager was in the process of registering with the CQC.
“At the time of our inspection there was not a registered manager in post. However, the manager of the service was in the process of registering with the CQC.” from the report
- 01Has the service manager now completed the CQC registration process?
- 02How are staff checking and reviewing each person's daily food and fluid intake?
- 03How often are staff training, supervision and appraisals checked, and what happens if anything is overdue?
- 04How are medicines, care plans, infection control and health and safety audits followed up?
- 05How will activities and one-to-one time be matched to my relative's interests, faith and communication needs?
This was a follow-up inspection of the two nursing units only; the separate acute inpatient mental health wards were not inspected. This explanation was written from the published report of 17 March 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 Grove Park
2 rated inspections over a year: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2023GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2022Insufficient evidence to rateSafe: Insufficient evidence to rateEffective: Insufficient evidence to rateWell-led: Insufficient evidence to rate
- August 2022Insufficient evidence to rateSafe: Insufficient evidence to rateEffective: Insufficient evidence to rateCaring: Insufficient evidence to rateResponsive: Insufficient evidence to rateWell-led: Insufficient evidence to rate
- February 2022
Registered with the Care Quality Commission on 18 February 2022.
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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