CQC report explained · a residential care home
What the CQC found at S E L F Limited - 15 Park View
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safer medicines management, improved financial safeguards, effective infection control and better checks on risks and incidents.
- Effective?
- Good
- People had more choice and their decisions were recorded in line with the law. Staff had improved training and support, worked with health professionals, and supported people with food, drink and healthcare.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- The new management team had improved quality checks, record keeping, incident reporting and the culture of the home. People and staff said they felt happier, valued and more involved.
What inspectors found, July 2022
S E L F Limited - 15 Park View was rated Good after improving from Inadequate; inspectors found safer, more respectful care and stronger management.
This was an unannounced focused inspection. The inspector spoke with five people living at the home and seven staff. An Expert by Experience telephoned relatives. The inspection team also reviewed care, medicines, staffing and management records.
Inspectors found major improvements since the previous inspection. People had more freedom and control, staffing levels had improved, medicines and finances were managed safely, and care records were clearer. The home had also improved its approach to safeguarding, incidents, infection control and staff training.
The overall rating was Good. Safe, Effective and Well-led were each rated Good. Caring and Responsive were not assessed during this visit, so their previous ratings were carried forward. The previous overall rating had been Inadequate.
More freedom and choice
People had more control over their daily lives. Restrictions on activities such as smoking, vaping, meals and access to money had been removed.
“People, including those unable to make decisions for themselves, now had as much freedom, choice and control over their lives as possible.” from the report
Enough staff
The provider had reviewed staffing and ensured enough staff were on duty. People received their planned additional one-to-one support.
“Enough staff were always on duty in the service. People now consistently received their allocated additional 1:1 support.” from the report
Safer medicines
Inspectors found that medicines were given as prescribed, with clear administration records and regular stock checks.
“People received their medicines as prescribed. There was a clear system in place for recording medicine administration and regular stock checks were carried out.” from the report
Better oversight
The new manager had improved audits, incident reviews and records. Action was taken when problems were identified.
“Audits now readily identify issues and prompt action is taken to resolve them.” from the report
Serious recent history
seriousAt the previous inspection, the home had a closed and restrictive culture that did not protect people's human rights. Inspectors found that this had changed, but families may still want to ask how the improvements are being maintained.
“The previous team were found to have created a closed, controlling and restrictive culture in the service, which had failed to promote people's human rights.” from the report
- 01How do you make sure people continue to have freedom over smoking, vaping, meals, medicines and their money?
- 02How do you maintain staffing levels and provide each person's planned one-to-one support?
- 03How are incidents, accidents and distress reviewed, and what changes are made when patterns are found?
- 04How are people's finances monitored while allowing them to manage their own money where possible?
- 05What evidence can you show that the improvements from the previous inspection have continued?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not assessed and their previous ratings carried over. This explanation was written from the published report of 27 July 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, December 2021
S E L F Limited - 15 Park View was rated Inadequate and placed in special measures; inspectors found unsafe systems, unlawful restrictions and poor leadership.
This was an unannounced focused inspection. Inspectors visited on 2 September, 27 September, 4 October and 8 October 2021. They spoke with people, staff and social care professionals, and checked care, medicines, staffing and management records.
The home was not safe. Risks were not always assessed or managed, financial records raised concerns about possible financial abuse, staffing levels were not always enough, and infection control records and procedures were not reliable. Some fire safety, care and confidential records were also incomplete or insecure.
People were subjected to restrictions including holding their cash cards, fixed smoking and vaping times, and fixed mealtime and medicine times. Inspectors said these restrictions removed people's choices and human rights. The provider stopped the unlawful restrictions after the inspection and said it was investigating the wider failings.
The overall rating fell from Good at the previous inspection to Inadequate. Safe, Effective and Well-led were all rated Inadequate. The home was placed in special measures and CQC said it would monitor progress and re-inspect.
Safe recruitment
Inspectors found that staff recruitment checks were carried out appropriately.
“Staff were recruited safely, and appropriate pre-employment checks were carried out.” from the report
Health support
The home had arrangements to refer people to health professionals, and people were supported to see health services when needed.
“People were supported to access the GP, and district nurses.” from the report
Compassionate care staff
Care staff were described as caring about people's lives and tried to raise concerns about the problems they saw.
“Care staff were compassionate about ensuring people lived full lives.” from the report
Financial safeguards
seriousFinancial records contained discrepancies, and older records could not be found. Inspectors referred their concerns to the police and a local authority safeguarding team.
“Discrepancies were found with people's financial records and the registered manager was unable to locate peoples' financial records dated before July 2021.” from the report
Risks and staffing
seriousCare records did not contain risk assessments, and the expected staffing levels were not achieved. Some people did not receive their planned one-to-one support.
“The provider's expected staffing levels were not achieved. This meant at times not enough staff were deployed to support people safely.” from the report
Infection control
seriousCOVID-19 checks were not always completed, protective equipment was not readily available, and testing, cleaning and temperature records were incomplete.
“The service did not have effective systems to prevent and control the spread of infections.” from the report
Poor management oversight
seriousAudits failed to identify problems with risks, finances, care records, infection control and management. Important records were incomplete, inaccurate or not securely stored.
“Quality assurance within the service was not effective.” from the report
Staff concerns not heard
needs fixingMost staff inspectors spoke with did not feel able to discuss problems openly. Staff reported low morale and said they were not listened to.
“Morale amongst staff was low. Staff told us they were not listened too when expressing their views.” from the report
- 01What evidence can you show that the restrictions on cash cards, smoking, vaping, mealtimes and medicines have stopped?
- 02How do you now assess and monitor each person's risks, including risks linked to behaviour?
- 03What staffing levels are planned for each shift, and how do you check that one-to-one support is delivered?
- 04How are people's money and financial records now protected and checked?
- 05What new audits and management checks are in place, and what happens when they find a problem?
This was a focused inspection of Safe, Effective and Well-led only; Safe, Effective and Well-led were inspected, while Caring and Responsive were not inspected and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 17 December 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.
Every inspection of S E L F Limited - 15 Park View
5 rated inspections over 7 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at S E L F Limited - 15 Park View →
- December 2021Inadequatedown from GoodSafe: InadequateEffective: InadequateWell-led: Inadequate
Read what inspectors found at S E L F Limited - 15 Park View →
- May 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- May 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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