CQC report explained · a residential care home
What the CQC found at Queens Park Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe recruitment, effective risk assessments, safe medicines arrangements and suitable infection control.
- Effective?
- Requires improvement
- Care, treatment and support did not always achieve good outcomes consistently. Staff training and care planning had improved, but one restriction did not have a recorded mental capacity assessment.
- Caring?
- Requires improvement
- This question was not given a rating in this report. Inspectors observed kind and sensitive support, respect for privacy and dignity, and good relationships between people and staff.
- Responsive?
- Requires improvement
- This question was not given a rating in this report. Inspectors found individualised care plans, support for people's choices and preferences, and opportunities for people to suggest activities and food choices.
- Well-led?
- Requires improvement
- Management and leadership had improved, but the service was not yet consistently well-led. Monthly audits were being completed, although the report said the audit systems still needed to be embedded and sustained.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found major progress from the previous Inadequate rating, but mental capacity records and quality checks still needed attention.
Inspectors visited unannounced on 6 December 2022 and spoke with two people who lived at the home and six staff. They reviewed care records, medicines records, recruitment and training records, and management documents.
The home was rated Good for Safe. Inspectors found enough staff, safe recruitment, effective safeguarding, safe medicines practice and improved risk assessments. Infection prevention and control arrangements were also satisfactory.
The home was rated Requires Improvement for Effective and Well-led. Most staff training, care planning and consent arrangements had improved, but one person did not have a recorded mental capacity assessment for a pressure mat, and the audit systems were not yet fully established.
The previous overall rating was Inadequate, with several breaches of regulations. The provider was no longer in breach at this inspection, and the home was no longer in Special Measures. The overall rating changed to Requires Improvement.
Safer care planning
Care plans and risk assessments had become clearer and more accurate. Staff had guidance for behavioural, physical and health needs, including enteral feeding and choking risks.
“At this inspection care plans reflected people's needs and demonstrated they had been assessed in line with best practice guidance.” from the report
Enough skilled staff
Inspectors found enough staff to meet people's needs. Staff had received relevant training and regular supervision and appraisals.
“There were enough staff to support people and meet their needs.” from the report
Kind, respectful support
People were supported with dignity and privacy. Inspectors saw a warm atmosphere and good relationships between staff and the people living there.
“People were supported in a kind and sensitive manner.” from the report
People's choices
Staff asked people for consent and supported their choices. People were involved in decisions about meals, activities, rooms and daily life.
“We observed staff ask people for consent and their choices when providing care.” from the report
Improved leadership
The new management team had made improvements since the previous inspection. Communication, care records, staff training records and accident records were better.
“Action had been taken following the last inspection to improve records relating to care records, staff training and accidents and incidents.” from the report
Mental capacity records
needs fixingOne person had a pressure mat used as a restriction, but there was no evidence of a mental capacity assessment for it. The manager took prompt action after inspectors raised this.
“Where people did not have capacity to make decisions, mental capacity assessments were not always completed.” from the report
Quality checks not yet established
needs fixingAudits were being completed monthly, but inspectors said the systems still needed to become established and remain effective. Some areas still needed improvement.
“Audit systems still needed to be embedded and improvements to these sustained by the provider.” from the report
No registered manager at the visit
minorThere was no registered manager in post when inspectors visited. A new manager had been in post for three months and had applied to register, but the application was still being assessed.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How do you now make sure every restriction has a completed and regularly reviewed mental capacity assessment?
- 02How will you show that the monthly audit system is working and that improvements are being sustained?
- 03Who is responsible for the home while the new manager's registration application is being assessed?
- 04What changes have been made since the previous Inadequate inspection, and how are these checked?
- 05How do you make sure the home can safely support up to 16 people when the report says it is larger than the guidance suggests?
This was an unannounced follow-up inspection after the previous Inadequate rating; inspectors reviewed Safe, Effective and Well-led, while the report does not give ratings for Caring or Responsive. This explanation was written from the published report of 7 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.
What inspectors found, October 2022
Rated Inadequate and placed in special measures; inspectors found serious safety, training and management failures.
Inspectors visited unannounced on 24 and 25 May 2022. They spoke with people, staff and two health professionals, observed care and reviewed care plans, medicines, staff files and management records.
The home had enough staff, managed medicines safely and followed infection control processes. Staff were mostly kind, supported daily choices and promoted independence. However, inspectors found unsafe care, incomplete records, poor care plans, delayed health referrals and insufficient staff training.
The ratings were Inadequate for Safe, Effective and Well-led. Caring and Responsive were rated Requires Improvement. The overall rating fell from Good at the previous inspection to Inadequate.
The home was placed in special measures. The provider was required to make improvements, and CQC said it would monitor the home and re-inspect to check for significant improvement.
Enough staff
Inspectors found enough staff to support people safely. Last-minute absences were usually covered, including with agency staff when needed.
“We saw there were enough staff to support people safely. People also told us there were enough staff.” from the report
Medicines
Medicines were stored safely, given as prescribed and recorded clearly. Guidance was available for medicines taken only when needed.
“Staff clearly recorded when medicines were given to a person. Medicines were given as prescribed.” from the report
Kind and respectful support
Staff were mostly kind, knew people's preferences and supported choices about daily routines, food and activities.
“People told us that staff were kind to them. One person said "They are polite and kind. They are always nice. I really like the staff here. They know me well.” from the report
Infection control
Inspectors were assured that infection prevention arrangements, including protective equipment, cleaning, testing and visiting processes, were being followed.
“We were assured that the provider was using PPE effectively and safely.” from the report
Unsafe care and missing records
seriousCare plans did not give clear instructions for some complex needs. Inspectors found unsafe enteral feeding, missed or poorly recorded catheter care and failure to follow advice about sitting upright after meals.
“People were not always kept safe from harm. This was a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Insufficient staff training
seriousSome staff had not been trained to provide restraint, catheter care, bladder washouts or enteral feeding safely. Staff had sustained injuries while supporting people.
“Staff had not received training in how to restrain a person safely.” from the report
Consent and restrictions
seriousMental capacity assessments and best-interest decisions were missing or incomplete for equipment and arrangements that restricted people's movement. One condition attached to a liberty authorisation had not been completed.
“People's human rights were not always respected with appropriate mental capacity assessments and best interest decision making.” from the report
Poor monitoring of weight and nutrition
needs fixingWeights were not recorded regularly, including after significant weight loss. The home did not always record drinks, and one dietitian referral was delayed by a month.
“There was a lack of effective action taken in response to weight loss at the service.” from the report
Weak management oversight
seriousThere were no effective audits of care records, weights or risks. Care plans were reviewed but were not corrected when they contained outdated or unsafe information.
“There has been a lack of oversight at the service to ensure risks are identified.” from the report
- 01What training have all staff now completed for restraint, enteral feeding, catheter care and bladder washouts?
- 02How do you now check that care plans are accurate and that required care, drinks, weights and health checks are recorded?
- 03What action has been taken following the warning notice for Regulation 12?
- 04How are mental capacity assessments, best-interest decisions and less restrictive options recorded for people whose movement is restricted?
- 05Has a registered manager been appointed, and what regular audits are now used to identify risks and missed care?
This was an unannounced inspection covering all five key questions, following concerns about food and staffing, with infection prevention and control also reviewed. This explanation was written from the published report of 6 October 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 Queens Park Care Home
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingup from InadequateSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateWell-led: Inadequate
- October 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 31 December 2010.
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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