CQC report explained · a residential care home
What the CQC found at Parkview Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People felt safe and there were enough staff, but recruitment checks were incomplete for some staff. Medicines records and arrangements for medicines awaiting disposal also needed further improvement.
- Effective?
- Good
- Inspectors found good support with food, drink and healthcare. The home had improved its training and its work around consent, mental capacity and Deprivation of Liberty Safeguards.
- Caring?
- Good
- Caring was not separately rated in this report. Feedback from people and relatives was positive, and inspectors observed positive interactions between staff and people.
- Responsive?
- Good
- Care plans were more personalised and reflected people's needs, preferences, communication and routines. People had activities, visitors and support to maintain relationships and independence.
- Well-led?
- Requires improvement
- Governance had significantly improved, including monitoring of care records, incidents and the environment. However, oversight had not identified that a recruitment file was incomplete, so further development was needed.
What inspectors found, August 2023
Parkview Residential Home was rated Requires Improvement; care had improved, but recruitment and medicines systems still needed strengthening.
This was an unannounced follow-up inspection on 25 July 2023. Two inspectors and a pharmacist reviewed care records, medicines, recruitment files, safety checks, incidents and quality monitoring. They spoke with people, relatives and staff, and observed care.
The home had improved since its previous Inadequate rating. People said they felt safe and spoke positively about staff. Inspectors found enough staff on duty, better care records, improved consent arrangements, good support with food and healthcare, and personalised care.
Some important problems remained. Recruitment checks were not always completed before staff were employed. Medicines prescribed for use when needed did not always have clear instructions or complete records, and medicines awaiting disposal were not stored securely enough. Some fire safety records and emergency evacuation plans were also incomplete.
The overall rating changed from Inadequate to Requires Improvement. The home was removed from Special Measures, but the provider must continue improving and send CQC an action plan. The registration conditions imposed after the previous inspection remained in place for the immediate future.
Kind and positive care
People and relatives spoke positively about the staff and the care they received. Inspectors observed positive interactions.
“I am very happy here, the staff are kind and caring.” from the report
Enough staff
Inspectors found enough staff on duty to meet people's needs, and people said staffing levels were positive.
“There were sufficient staff on duty to meet people's needs.” from the report
Personalised care plans
Care plans had been rewritten to include people's histories, preferences, routines, communication needs and desired outcomes.
“The care plans were now reflective of people's current needs and contained personalised detail.” from the report
Improved leadership systems
The home had introduced systems to monitor care records, accidents, falls, environmental safety and mental capacity paperwork. These systems were still being embedded.
“There were new governance systems in operation to ensure the health, safety and welfare of people using the service and others.” from the report
Incomplete recruitment checks
seriousSome staff had been employed without all required references and a full employment history. This remained a legal breach and created a safety risk.
“Not all new staff had been recruited safely.” from the report
Medicines used when needed
needs fixingMedicines prescribed for use when needed did not always have clear protocols or complete records. Variable doses were not always recorded fully.
“However, there were no protocols for these medicines and details were not always recorded in people's care plans.” from the report
Medicines awaiting disposal
needs fixingThe storage and security of medicines waiting to be returned to the pharmacy needed improvement.
“We identified that improvements were needed in relation to the current storage arrangements and security of medicines awaiting return to the pharmacy.” from the report
Fire safety records
needs fixingFive recent admissions did not have emergency evacuation plans in the fire folder. Weekly extinguisher checks and recent evacuation drills were not recorded.
“However, we identified that following a recent number of new admissions, 5 were missing from the folder and had not been completed.” from the report
End of life records
minorEnd of life care had improved, but some records still needed to be more personal and reflect people's final wishes.
“The registered manager was aware some records still required further development to ensure they were fully personalised reflecting people's final wishes within the service and after they had passed away.” from the report
- 01How do you now check references, previous work with vulnerable adults and full employment histories before employing staff?
- 02What written protocols do you use for medicines prescribed when needed, and how do you record variable doses?
- 03How are medicines awaiting return to the pharmacy kept secure and monitored?
- 04Are every person's emergency evacuation plan, weekly extinguisher checks and evacuation drills now completed and recorded?
- 05What action has been taken in response to CQC's request for an improvement action plan?
This was an unannounced follow-up inspection covering Safe, Effective, Responsive and Well-led; Caring was not separately rated in the report. This explanation was written from the published report of 25 August 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, January 2023
Rated Inadequate and placed in special measures; inspectors found unsafe medicines and weak management despite kind, respectful care.
The inspection was unannounced and took place on 29 November 2022. One inspector spoke with people, staff and a relative, observed care, and checked care records, medicines, recruitment files, safety checks, accidents and quality records.
Inspectors found serious safety and management problems. Medicines systems were unsafe, care records did not always show people's current needs, and risks such as falls, choking and fire safety were not managed well. Some staff recruitment checks had not been completed properly.
The home did provide kind and respectful care. People were offered choices, treated with dignity and supported to keep in touch with visitors. However, inspectors found that the quality of care was not reliably supported by suitable records, training or oversight.
The overall rating changed from Good in 2019 to Inadequate. Safe and well-led were rated Inadequate. Effective and responsive were rated Requires Improvement. Caring remained Good.
Kind and respectful care
People and relatives spoke positively about the staff. Inspectors saw respectful, person-centred interactions and support for people's independence.
“We observed staff offering people choices and people were communicated with respectfully. Interactions were tailored to the individual and were person-centred in their approach.” from the report
Safeguarding awareness
Staff knew how to identify and report safeguarding concerns, including to outside agencies.
“People were protected from the risk of abuse as staff knew how to report concerns within the service and how to raise concerns with external agencies.” from the report
Prompt call bell responses
Inspectors saw call bells being answered promptly during the visit.
“During the inspection, we observed call bells were responded to promptly.” from the report
Food and drinks
People gave positive feedback about the food. They were offered drink choices and had drinks available in their rooms.
“People were observed being offered choices of drinks and there were drinks available to people in their rooms.” from the report
Medicines were not managed safely
seriousRecords and procedures for ordering, administering, checking and returning medicines were inadequate. This included incomplete guidance for medicines taken when needed and missing checks of staff competence.
“The systems to order, store, administer, audit and return medicines were inadequate and this placed people at risk of harm.” from the report
Risks and fire safety
seriousCare records did not always show current risks, including possible choking and behaviours that may challenge. The fire risk assessment shown to inspectors was 14 years old and emergency evacuation plans were not available in the fire grab bag.
“The fire risk assessment in use by the service at the time of the inspection was historical and emergency evacuation plans were not available” from the report
Accidents were not reviewed
seriousThere was no effective system to identify patterns in falls and other incidents. Some records could not be found, so lessons may not have been learned.
“There was no formal system to ensure accidents and incidents were monitored by the service management to identify any patterns or trends.” from the report
Consent and liberty safeguards
seriousThe home had not made applications where people might need legal authorisation to be deprived of their liberty. Staff had not been trained well enough in the Mental Capacity Act and related safeguards.
“There was no evident understanding by the provider or service manager in relation to the MCA or DoLS.” from the report
Care plans lacked detail
needs fixingCare plans did not always reflect people's current needs or describe meaningful outcomes. End of life information was also inconsistent.
“Every person at the service had a care plan, however these plans were not always reflective of their current needs and lacked detail.” from the report
Training was incomplete
needs fixingThere was no training provision in dementia or challenging behaviour, and staff had not received training in end of life care. Inspectors recommended that the provider seek advice about training.
“There was currently no staff training provision in place for either dementia or challenging behaviour which placed people at risk of unsafe or inappropriate care” from the report
- 01What has been corrected in the medicines system, and how are staff medicines training and competency now recorded?
- 02What is the current fire risk assessment, and where are each person's emergency evacuation plans kept?
- 03How are falls, accidents and incidents now recorded, reviewed and used to prevent repeat harm?
- 04Which staff have completed training in dementia, challenging behaviour, the Mental Capacity Act and end of life care?
- 05How have care plans and end of life wishes been updated to reflect each person's current needs and preferences?
This was an unannounced inspection prompted by concerns about statutory notifications and it assessed all five key questions, including infection prevention and control. This explanation was written from the published report of 13 January 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 Parkview Residential Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2023Inadequatedown from GoodSafe: InadequateEffective: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- November 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 11 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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Most charge £1,020 to £1,270 a week. 15 can care for a couple. 13 years' experience on average.
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