CQC report explained · a residential care home
What the CQC found at SELF Limited - 16 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, safe medicines systems, improved financial safeguards, effective infection control and better management of risks and incidents.
- Effective?
- Good
- People had more choice and freedom, and staff followed the law when making decisions for people. Inspectors also found suitable support with food, healthcare, staff training and personalised rooms.
- Caring?
- Good
- This area was not looked at in this focused inspection. The report says ratings for areas not inspected were carried over from the previous comprehensive inspection.
- Responsive?
- Good
- This area was not looked at in this focused inspection. The report says ratings for areas not inspected were carried over from the previous comprehensive inspection.
- Well-led?
- Good
- Management oversight, quality checks, record keeping and reporting had improved. Inspectors found a more open, inclusive and person-centred culture.
What inspectors found, July 2022
SELF Limited - 16 Park View was rated Good; inspectors found major improvements in safety, choice and management after a previous Inadequate rating.
This was an unannounced focused inspection over four visits in June 2022. The inspector spoke with four people, eight staff and relatives by telephone. Records about care, medicines, staffing and management were also checked.
The home was rated Good for Safe, Effective and Well-led. Inspectors found enough staff, safer medicines systems, better risk management, improved care records and much greater freedom and choice for people.
The home had previously been rated Inadequate. Inspectors said the earlier restrictive culture and other serious problems had been addressed. This inspection checked the required improvements, rather than carrying out a full review of every area of care.
More freedom and choice
People were no longer subject to the earlier restrictions on their money and outings. Staff supported people to have more control over their lives.
“People now had as much freedom, choice and control over their lives as possible.” from the report
Enough staff
The provider reviewed staffing and created a dedicated team. Inspectors found enough staff were always on duty.
“People told us staff were now always available, which was a vast improvement and they appreciated the support.” from the report
Safer systems
Risk assessments, medicines records, financial arrangements and incident reviews had all improved. Inspectors found that incidents were analysed to reduce the chance of them happening again.
“Robust processes were now in place for monitoring incidents.” from the report
Better care records
Care plans were described as personal and up to date. People and those important to them were involved in reviewing support.
“Staff now kept clear and detailed care records, which were accurate, complete, legible and up to date.” from the report
Serious recent history
needs fixingThe previous management team had created a restrictive and controlling culture that did not protect people's rights. Although inspectors found substantial improvement, families may want to check how these changes are being maintained.
“The previous team had 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 control their own money, outings and daily routines?
- 02How many staff are on duty at different times, and how do you cover sickness or vacancies?
- 03How are incidents reviewed, and what recent changes have been made because of what was learned?
- 04How do people and their relatives take part in reviewing care plans and checking that support reflects their wishes?
- 05What checks are now used to make sure the more open and inclusive culture is maintained?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. 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, January 2022
Rated Inadequate and placed in special measures; inspectors found serious problems with safety, staffing, unlawful restrictions and management.
This was an unannounced focused inspection. Inspectors visited on four dates in September and October 2021. They spoke with people living in the home, staff and social care professionals, and checked care, medicines, staffing and management records.
Inspectors found that risks were not always managed, there were not enough staff at times, and infection control procedures were not consistently followed. They also found weak protection against financial abuse and restrictions on people's freedom that were not properly authorised. Medicines were managed safely, and staff received training, supervision and appraisals.
The overall rating fell from Good at the previous inspection to Inadequate. The home was placed in special measures. A warning notice was issued for poor governance, and the provider was told to make improvements. The provider said it had taken steps to reduce risks, and CQC said it would continue to monitor and re-inspect.
Medicines
Inspectors found that medicines were managed safely and people received them as prescribed. Records and stock checks were in place.
“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
Staff commitment
Staff were described as compassionate and committed to helping people live full lives. Some worked extra hours to help keep people safe.
“Care staff were compassionate about ensuring people lived full lives.” from the report
Healthcare support
People were supported to access healthcare professionals when needed. Professionals told inspectors that staff had helped people achieve positive outcomes.
“The service had systems and procedures in place to refer people to other professionals when required.” from the report
Staff development
The home had a training programme, and new staff received an induction and worked alongside experienced staff. Staff also had supervision and appraisals.
“New members of staff completed an induction and a period of working with experienced staff.” from the report
Unmanaged risks
seriousKnown risks were not always acted on, and behaviour that could challenge others was not monitored robustly. This could make it harder to keep people safe.
“Risks to people were not managed safely. Action was not taken to manage known risks to people.” from the report
Financial abuse safeguards
seriousThe home did not have effective systems to protect people from financial abuse. CQC raised concerns with the police and an investigation was ongoing.
“People were not protected from the risk of financial abuse. The service did not have effective systems to prevent financial abuse.” from the report
Unlawful restrictions
seriousAt least one person was required to go out with staff without a clear legal basis, care plan or agreement. Inspectors found that people's freedom was not always protected by the law.
“There was no information to explain on what legal basis they had to have staff accompany them” from the report
Staffing levels
seriousRotas did not always match the staff actually on duty, and expected staffing levels were not achieved. People could miss community activities because there were not enough staff.
“This meant at times not enough staff were deployed to support people safely.” from the report
Infection control
seriousCOVID-19 checks, PPE arrangements, cleaning records and staff testing records were not consistently managed. Inspectors found a breach even though they found no evidence that people had been harmed.
“The service did not have effective systems to prevent and control the spread of infections.” from the report
Poor oversight
seriousAudits did not identify the problems found during the inspection. The management team did not have effective systems to monitor quality, risks and safety.
“Quality assurance within the service was not effective. Audits had failed to identify the issues found during this inspection” from the report
- 01What has changed to protect residents from financial abuse, and how are residents' finances now checked?
- 02Which restrictions on residents' freedom have been reviewed, and what legal authorisation or best-interests decision supports each one?
- 03How do you now make sure staffing rotas accurately show who is on duty and that enough staff are available for community activities?
- 04What new checks are in place for visitor screening, PPE, cleaning records and staff COVID-19 testing?
- 05What evidence can you show that your quality audits now identify and correct risks before they affect residents?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected, and previous ratings for those questions were used in calculating the overall rating. This explanation was written from the published report of 14 January 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 SELF Limited - 16 Park View
4 rated inspections over 7 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022Inadequatedown from GoodSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- May 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2014
Registered with the Care Quality Commission on 27 November 2014.
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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46 live-in carers within about an hour of Sunderland
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Most charge £950 to £1,210 a week. 42 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
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