CQC report explained · a residential care home
What the CQC found at Park View
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks were not managed well and some safeguarding concerns, including medication errors and altercations, were not always reported to the local authority. There were enough staff, recruitment checks were completed and medicines arrangements were described as safe.
- Effective?
- Requires improvement
- Mental capacity assessments were not always completed for restrictive practices, and staff supervision was inconsistent. People received enough food and drink and were supported with healthcare appointments, but one person's required observation while eating did not always happen.
- Caring?
- Good
- People and relatives gave positive feedback about the care. Inspectors found that people were treated with dignity and respect and supported to remain as independent as possible.
- Responsive?
- Good
- Support plans were personalised and staff knew people's needs and preferences. People could take part in activities and hobbies of their choice, and systems were in place for complaints.
- Well-led?
- Requires improvement
- Audits did not identify the concerns found during the inspection. Meetings, satisfaction surveys and staff supervision were inconsistent, and the home did not have a registered manager at the time.
What inspectors found, October 2023
Rated Requires Improvement; inspectors found kind, person-centred care but gaps in risk management, safeguarding and oversight.
Inspectors visited unannounced from 10 to 23 August 2023. They spoke with people living at the home, relatives and staff, and reviewed care plans, recruitment files, training records and quality checks.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also Requires Improvement. Caring and Responsive were rated Good.
Inspectors found enough staff, safe recruitment, generally safe medicines arrangements and positive, kind care. However, some risks and safeguarding concerns were not managed or reported properly. Records and checks did not always identify problems.
The previous overall rating was Good, published in October 2018. The home must send the provider's action plan to CQC, which will continue to monitor the service.
Kind and respectful care
People and relatives described staff as kind, patient and supportive. Inspectors found that people were treated with dignity and respect.
“Staff are always helpful, they are fantastic. Always on hand.” from the report
Enough staff
People, relatives and staff told inspectors there were enough staff to meet people's needs safely.
“There were enough staff employed to care for people safely.” from the report
Personalised support
Care plans included people's preferences, and staff knew how people wanted their support delivered.
“Support plans were personalised and contained information for staff about how people wanted their care and support to be carried out.” from the report
Activities and independence
People were supported to pursue hobbies, go out and develop living skills. Some people could make their own meals.
“People were able to learn and develop new living skills to increase their independence” from the report
Medicines arrangements
Staff were trained and checked as competent to give medicines. Medicines were stored securely and records had no missing signatures.
“Medication records were completed accurately by staff with no missing signatures.” from the report
Safeguarding reporting
seriousSome safeguarding concerns were not reported to the local authority for further investigation. These included medication errors and altercations between people.
“some safeguarding concerns were not always reported to the local authority for further investigation.” from the report
Risk assessments
needs fixingRisk assessments were missing after some incidents, including people smoking in bedrooms or communal areas. The assessments were added during the inspection.
“Some risk assessments were not in place when incidents within the home had occurred.” from the report
Restrictive practices and capacity
seriousSome people were not allowed to keep their own lighters and cigarettes, but the required mental capacity assessments had not been completed beforehand. These were completed during the inspection.
“Correct procedures were not followed if people lacked the capacity to make their own decisions.” from the report
Eating safety
seriousOne person's plan required constant observation because they could rush their food and might choke. Inspectors did not always see this support being provided.
“We saw this was not always done during the inspection.” from the report
Quality oversight
seriousThe home's audits did not identify the concerns about risks, incidents, capacity assessments, supervision and meetings. This led to a breach of the good governance regulation.
“Audits were completed at the service, although they had not identified these concerns” from the report
Inconsistent management arrangements
needs fixingStaff supervision, resident meetings, staff meetings and satisfaction surveys did not happen consistently. The home also did not have a registered manager during the inspection.
“At the time of the inspection, the home did not have a registered manager.” from the report
- 01What action has been taken to make sure every safeguarding concern, medication error and altercation is reported to the local authority when required?
- 02How are risk assessments now reviewed after incidents, including smoking in bedrooms or communal areas?
- 03How do you check that mental capacity assessments and best-interest decisions are completed before restrictive practices are used?
- 04How do you make sure people who need observation while eating receive it every time?
- 05Has the new manager registered with CQC, and how are audits, staff supervision, meetings and satisfaction surveys now being kept up to date?
This inspection looked at all five CQC questions and both the premises and care provided; ratings for Caring and Responsive remained Good, while the other ratings changed from Good to Requires Improvement. This explanation was written from the published report of 7 October 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 2022
Inspected but not rated; inspectors found good COVID-19 controls but some gaps in visitor screening and entrance security.
This was an announced, targeted inspection on 23 February 2022. Inspectors looked at infection prevention and control, and asked about staffing pressures during the COVID-19 pandemic.
The home had testing arrangements, enough personal protective equipment, vaccination requirements for staff, and plans for safe admissions and self-isolation. Inspectors found the home clean and tidy, with enough staff to care for people safely.
The inspectors were only somewhat assured about preventing visitors from catching and spreading infections. The entrance was not staffed throughout the day, so visitors might enter without showing a test result or wearing suitable protective equipment. The overall service and Safe question were inspected but not rated.
Testing and isolation
The home had testing arrangements for staff and residents. It also used zoning and self-isolation arrangements when needed.
“Zoning arrangements were used if people needed to self-isolate in certain areas of the home, such as bedrooms.” from the report
PPE and cleanliness
There was enough PPE, staff wore it during the visit, and the home was clean and tidy.
“Enough PPE was available and staff wore it at all times during our visit.” from the report
Staffing
Inspectors found enough staff to care for people safely. Agency and bank staff were used to cover gaps when regular staff were unavailable.
“There were enough staff to care for people safely, with staff receiving additional infection control training during the pandemic.” from the report
Safe admissions
The home had arrangements for new admissions, including asking for a negative COVID-19 test and a period of self-isolation.
“Appropriate arrangements were in place for new admissions, such as requesting confirmation of a negative COVID-19 test and completing a period of self-isolation.” from the report
Unstaffed entrance
needs fixingThe main entrance was not staffed throughout the day. This meant visitors could potentially enter without showing an LFT result or wearing suitable PPE.
“the main entrance to the home was not staffed throughout the day meaning anybody could access areas of the home without showing evidence of their LFT result, or potentially not be wearing appropriate PPE.” from the report
Incomplete vaccination records
minorVaccination information for visiting health professionals was not clearly recorded on the screening questionnaire. The manager said this would be updated.
“We also spoke with the manager about ensuring vaccination records for visiting health professionals were clearly documented on the screening questionnaire used.” from the report
- 01How do you now make sure every visitor shows an LFT result and wears the right PPE before entering?
- 02Has the main entrance been made more secure or staffed throughout the day?
- 03How are vaccination records for visiting health professionals now recorded?
- 04How do you cover staff shortages with agency or bank staff without affecting people's care?
This was a targeted inspection of infection prevention and control and staffing pressures; the service and Safe question were inspected but not rated, and the other questions were not assessed. This explanation was written from the published report of 18 March 2022 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
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- October 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- October 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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