CQC report explained · a residential care home
What the CQC found at Park View Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- The home was generally following infection control arrangements, but visitors were not screened when the inspector arrived and used PPE was not disposed of in line with guidance. This part of the Safe question was inspected but not fully rated.
- Effective?
- Requires improvement
- The home remained in breach of Regulation 11. Restrictions and decisions made for people were not always supported by accurate capacity assessments or evidence that less restrictive options had been considered.
- Caring?
- Good
- Caring was not assessed in this targeted inspection.
- Responsive?
- Good
- Responsive was not assessed in this targeted inspection.
- Well-led?
- Requires improvement
- There was no registered manager, the interim manager was still developing their knowledge of the role, and audits did not contain enough evidence or action planning. Staff said they felt supported and that the team worked well together.
What inspectors found, May 2021
Rated Requires Improvement; inspectors found ongoing problems with consent, restrictions and capacity assessments, although there was no evidence that people had been harmed.
This was an unannounced targeted inspection on 18 March and 1 April 2021. Inspectors checked whether the home had followed an earlier action plan about restrictions, independence and consent. They also checked infection prevention and control.
The home had not made enough improvement. Staff placed restrictions on access to the front door, kitchen knives and cleaning products, but records did not show that less restrictive options had been considered. Some mental capacity assessments were inaccurate, including for a person whose capacity could change.
The overall rating remained Requires Improvement. The three areas inspected were marked Inspected but not rated because this was a targeted inspection. The home remained in breach of Regulation 11 about consent, and CQC asked for an action plan and said it would monitor progress.
Infection control arrangements
Inspectors were assured about most of the home's infection prevention arrangements, including social distancing, testing, hygiene and outbreak planning.
“We were assured that the provider was meeting shielding and social distancing rules.” from the report
Staff support
Staff said they felt supported by management and able to raise concerns or suggestions.
“Staff said they felt supported by the management and they felt the team worked well together.” from the report
Willingness to improve
The management team accepted feedback and was willing to improve its knowledge and practice.
“The management team welcomed feedback and were willing to look at how they can improve their knowledge and practice.” from the report
Restrictions were not properly reviewed
seriousPeople faced restrictions on the front door and locked cupboards or drawers. Records did not show that other, less restrictive arrangements had been considered.
“However, records did not indicate that alternative arrangements had been considered, to ensure this was the least restrictive option.” from the report
Inaccurate capacity assessments
seriousSome assessments did not accurately reflect people's capacity, including fluctuating capacity. This meant decisions were made for people when they may have been able to decide for themselves.
“Mental capacity assessments were not always completely accurately, especially where people had fluctuating capacity.” from the report
Privacy and dignity
needs fixingThe inspector was taken into a person's bedroom while they were sleeping. The report said this did not respect their privacy.
“During the inspection we were shown into a person's bedroom whilst they were sleeping, which was not appropriate and demonstrated a lack of consideration for their privacy.” from the report
Weak quality checks
needs fixingThe home's audits did not contain enough evidence or action planning to identify and address the problems found.
“The quality assurance systems where not robust enough to recognise improvements were needed to meet best practice guidance and legislation.” from the report
PPE disposal
needs fixingUsed PPE was not disposed of in line with guidance. Visitors were also not temperature-checked or health-screened when the inspector arrived.
“We were assured that the provider was using PPE effectively and safely. disposal of used PPE was not in line with guidance.” from the report
- 01How do you now check that each person's mental capacity assessment is accurate, especially when their capacity fluctuates?
- 02What alternatives have you considered to the locked front door and locked cupboards or drawers, and how do you show that any restriction is the least restrictive option?
- 03How do you make sure people can make their own decisions rather than having decisions made for them?
- 04What changes have been made to quality audits and action plans since this inspection?
- 05How are visitors now health-screened, and how is used PPE disposed of?
This was a targeted inspection of specific concerns about consent, mental capacity, restrictions, human rights and infection control; it did not assess the full key questions, so the previous ratings carried over. This explanation was written from the published report of 13 May 2021 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, May 2019
Rated Requires Improvement; inspectors found safe, kind care, but consent, independence and quality checks were not always handled properly.
This was an unannounced, comprehensive inspection on 7 March 2019. Inspectors spoke with people using the service and a relative. They reviewed care records, staff files, audits and other records.
People were safe, medicines were managed properly and the home was clean. Inspectors also found kind relationships with staff, regular staffing and support from health professionals.
The main problem was that some restrictions on people's freedom had not been properly considered under the Mental Capacity Act. This included controlling access to cigarettes and locking kitchen cupboards without considering less restrictive options.
The overall rating changed from Good at the previous inspection to Requires Improvement. The Effective and Well-led areas were rated Requires Improvement. The service had breached Regulation 11, concerning consent.
People were safe
Inspectors found enough staff, safe recruitment and safe medicines management. People had emergency evacuation plans and equipment was maintained.
“There were enough staff available to keep people safe.” from the report
Kind relationships
People appeared comfortable with staff. Inspectors saw support that was kind and caring, with people's dignity and privacy respected.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Clean environment
The home was clean and staff had relevant infection control and food hygiene training. There was also a separate building for activities and social occasions.
“The service was clean throughout the home.” from the report
Support with health
People were supported to attend appointments with health professionals. Food and drink support included weight checks, risk assessments and modified food where needed.
“People were supported to attend appointment with health care professionals to maintain good health this included GP, Community Nurses, optician, dentist and SALT.” from the report
Restrictions were not properly authorised
seriousThe home restricted access to cigarettes and kitchen cupboards without properly considering people's mental capacity, best interests or less restrictive options. This was the report's identified breach.
“The provider did not consider less restrictive ways to support people to make an informed choice.” from the report
Independence and activities
needs fixingActivities were limited and staff did not consistently encourage people to take part or develop their independence. Care plans also lacked guidance on reducing anxiety.
“At the time of the inspection there was limited activities happening during the day.” from the report
Quality checks missed problems
needs fixingThe home's audits did not identify the problems inspectors found with mental capacity, support plan information and reviews of as-needed medicines.
“However, these audits had not identified the issues in relation to MCA, required support plan information and as required medicines reviews.” from the report
Mental capacity reviews
seriousSome mental capacity assessments had not been reviewed since 2014, even though people's needs might have changed. Other restrictions had not been considered as possible deprivation of liberty.
“MCA assessments were completed in some cases; however, these had not been reviewed since 2014 despite people's needs possibly changing in this time.” from the report
- 01What has changed to make sure restrictions on cigarettes, kitchen cupboards and other parts of daily life are properly assessed and legally authorised?
- 02Have all mental capacity assessments been reviewed, and are best-interest decisions recorded where people cannot decide for themselves?
- 03How do you now promote people's independence, choice and control over their lives?
- 04What varied activities are now available, and how are people supported to take part?
- 05How are as-needed medicines and care plan information reviewed and checked by the management team?
This was an unannounced, planned comprehensive inspection covering all five CQC questions; the previous inspection in August 2016 had rated the service Good. This explanation was written from the published report of 14 May 2019 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 Park View Residential Home
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- May 2021Inspected but not ratedcurrent ratingSafe: Inspected but not ratedEffective: Inspected but not ratedWell-led: Inspected but not rated
- May 2019Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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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