CQC report explained · a nursing home
What the CQC found at Royal Park
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Individual risks were not always managed safely, and care plan instructions were not always followed. Medicines, staffing, safeguarding and infection control were found to be in place.
- Effective?
- Requires improvement
- The home was not always working within the principles of the Mental Capacity Act. Capacity assessments, best-interest decisions and consideration of restrictions were incomplete.
- Caring?
- Good
- This question was not reviewed during this focused inspection. People said staff were kind and helpful and that they were involved in their care.
- Responsive?
- Good
- This question was not reviewed during this focused inspection. People had care plans and opportunities to be involved in reviews, but the report did not give a rating for this question.
- Well-led?
- Requires improvement
- The home’s records and systems were disorganised, and audits failed to identify several risks. Some other audits, such as medicines audits, did identify problems and led to improvements.
What inspectors found, November 2022
Rated Requires Improvement; inspectors found risks were not always managed safely and care records and oversight were not reliable.
This was an unannounced focused inspection on 1 November 2022. Inspectors looked only at Safe, Effective and Well-led, after concerns about tracheostomy care, PEG care and urine infections. They spoke with people and staff, reviewed seven care records and checked the home’s records and audits.
The home was not always safe. Care plans were not always followed, fluid input and output for people with catheters was not monitored, and blood sugar checks were not consistently recorded. Pressure mattress settings had not been assessed for individuals, and there was not enough guidance for periods of emotional distress.
The home was not always effective or well-led. Capacity assessments and best-interest decisions were missing or incomplete, and some restrictions were not properly considered. Information was split between paper and electronic systems, while audits did not identify several important problems.
There were also positive findings. Medicines were managed safely, infection control procedures were followed, and staff numbers, training and recruitment checks were suitable. People had access to health professionals, enjoyed the food and said staff were kind. The overall rating fell from Good at the previous inspection in 2019 to Requires Improvement.
Medicines
Inspectors found that medicines were administered and stored safely. Staff had training and regular checks of their competence.
“Medicines records we reviewed showed medicines were administered to people when needed and in a safe way.” from the report
Staffing and training
There were enough staff, and call bells were answered promptly. Recruitment checks and training, including training for tracheostomy care and epilepsy, were in place.
“We saw when people needed support this was provided for them in a timely manner.” from the report
Infection control
Inspectors were assured that the home used infection control measures, including suitable protective equipment and procedures for managing infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Kind and involved care
People said they were happy living in the home and felt involved in their care. Staff were described as kind and helpful.
“People told us, and we saw they were involved with their care.” from the report
Learning from incidents
The home reviewed incidents and had introduced a board showing lessons learned and changes made.
“A lesson learned board had been introduced and was displayed within the home” from the report
Individual risks not monitored
seriousCatheter fluid records, blood sugar records and pressure mattress assessments were not consistently completed. This meant inspectors could not be assured that some important care was being provided safely.
“Individual risks to people were not always managed in a safe way.” from the report
Mental capacity and restrictions
seriousCapacity assessments and best-interest decisions were missing or incomplete. Some restrictions, including bedrails and 24-hour support, were not fully considered.
“Furthermore, we did not see any best interest decisions in place for people.” from the report
Disorganised information
needs fixingInformation was held across paper and electronic systems and was not always stored together. Inspectors said this could delay staff finding important information in an emergency.
“Some information was stored on the electronic system and some was paper, information that related to a person was often not stored together.” from the report
Weak oversight
seriousThe home’s audits did not identify several concerns, including missing capacity assessments, unmonitored fluids, pressure mattress issues and incomplete blood sugar records.
“There was insufficient oversight on the service and the measures in place were not always effective in identifying areas of improvement.” from the report
Emotional distress guidance
needs fixingCare plans and risk assessments did not give clear enough instructions for staff supporting people during periods of emotional distress.
“When people displayed periods of emotional distress, there was no clear guidance, care plans or risk assessments to show how to support people during these times.” from the report
- 01What action has been taken to ensure catheter fluid input and output is recorded for every person who needs this?
- 02How do you now check that blood sugar monitoring and pressure mattress settings are completed as required in each person’s care plan?
- 03Can you show how capacity assessments and best-interest decisions are recorded, including for people using bedrails or receiving 24-hour support?
- 04How are paper and electronic records now brought together so staff can quickly find urgent information?
- 05What was included in the action plan sent to the CQC, and what improvements have been checked since the inspection?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not reviewed and no ratings were given for them. This explanation was written from the published report of 17 November 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.
What inspectors found, May 2019
Rated Good; inspectors found safe, kind and effective rehabilitation care, but staff raised concerns about the manager's communication style.
Inspectors visited on 8 and 9 May 2019. They spoke with people living at the home, a relative, staff and outside professionals. They looked at care records, medicines records, staff files, accidents, activities, equipment and quality checks.
The home supports up to 18 people with complex neurological needs, including artificial ventilation and tracheostomies. Inspectors found enough staff, safe medicines practices, suitable training and good teamwork between care staff, nurses and therapists.
People were treated kindly and with respect. Care was personalised, and staff supported rehabilitation, independence, choice and contact with relatives. The home also worked with health and social care professionals when people's needs changed.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This was the first published inspection because the home registered with CQC in June 2018.
Safe staffing
Inspectors found enough staff to meet people's needs promptly and flexibly. Staff recruitment checks were also in place.
“There were enough staff to meet people's needs in a timely and flexible way.” from the report
Rehabilitation teamwork
Care staff, nurses and therapists worked together and understood people's individual rehabilitation goals. The home supported people to build independence and prepare for future care or accommodation.
“People were supported by care staff, nurses and on-site therapists who worked well as a team” from the report
Kind and respectful care
People and relatives described staff positively. Inspectors observed staff protecting privacy, explaining care and encouraging people to do what they could for themselves.
“People, relatives and professionals described the staff as kind, caring and attentive to people's needs.” from the report
Listening to feedback
The home used surveys, meetings and a 'You Said, We Did' display to show how people's views led to changes, including weekend therapy.
“The home had a 'You Said, We Did' display to let people know what actions had been taken following their feedback.” from the report
Manager's communication style
needs fixingSome staff said the manager raised their voice and used an inappropriate tone in communal areas. Management said they were working to address this and would continue monitoring it.
“Staff provided mixed reviews about the registered manager's management style when engaging with them around the home.” from the report
Activities staffing
minorThe home was waiting for recruitment checks to be completed for the activities coordinator post. Ask how activities were covered during this period.
“At the time of the inspection, the home was waiting for recruitment checks to be completed for the activities coordinator post.” from the report
- 01What action has been taken since the inspection to address staff concerns about the manager raising their voice or using an inappropriate tone?
- 02How do you now monitor staff views about management and the atmosphere in the home?
- 03Who provides activities while recruitment checks for the activities coordinator are completed?
- 04How will you support my relative's individual rehabilitation goals, and how often will these be reviewed?
- 05How will my relative's nursing, therapy and care teams share information if their needs change?
This was a scheduled inspection covering all five CQC questions and both the care provided and the premises; it was the first published inspection because the home registered in June 2018. This explanation was written from the published report of 25 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 Royal Park
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2019GoodSafe: GoodEffective: GoodWell-led: Good
- June 2018
Registered with the Care Quality Commission on 1 June 2018.
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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