31 March 2023
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
The inspection was carried out by 3 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Park Hall is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Park Hall is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was not a registered manager in post. A new manager had been in post for about 8 weeks and had planned to apply to register. We will assess this application once received.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of a monitoring activity that took place on 13 May 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.
During the inspection
We spoke with 3 people who used the service and 17 relatives about their experience of the care provided. Some relatives were spoken with during the site visit but the majority were spoken with by the Expert by Experience over the telephone. We spoke with 13 staff members including; the home manager, deputy manager, district manager, team leaders, chef manager, handyperson, care assistants, administrator, and wellbeing coordinator.
We viewed a range of records. This included 7 people’s care records and multiple medicine records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service, including; quality audits and policies and procedures were reviewed.
We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
31 March 2023
About the service
Park Hall is a residential care home providing personal care to up to 60 people. The service provides support to adults and older people, some of whom may have dementia. At the time of our inspection there were 58 people using the service. Park Hall accommodates people in one adapted building over 2 floors.
People’s experience of using this service and what we found
Quality assurance systems were not robust enough. People did not always have health-specific risk assessments in place. Medicines were generally safely managed, although some ‘as and when’ protocols needed more details. Building safety checks were completed. People and their relatives felt they were safe and protected from abuse. There were enough safely recruited and suitably trained staff. Staff were preventing infections in the home and visitors were supported to come into the home safely. Lessons were learned when things went wrong.
People had care plans in place, but some were not updated to reflect a change in need and actions had not been taken to seek professional input. People’s cultural and religious needs were considered as part of their care planning. Staff were supported through supervisions and meetings. People were supported in line with their dietary needs. The home was clean and well-maintained. Staff supported people in line with other professionals’ recommendations.
Systems in place were not always robust enough to identify errors or to make sure they were acted on in a timely manner. People, relatives and staff felt the home was well-managed. There was a learning culture in the service and an action plan in place to address areas of concern. The home manager was responsive to our feedback and resolved issues both during and after the inspection.
No one was at the end of their life, specific training for staff had been planned around this area of support. People had personalised care plans in place. People’s communication had been considered as part of their care plans. People were supported to participate in activities of their own choice and staff supported people to maintain contact with their relatives. People and relatives were able to raise concerns.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Staff were caring and respected people’s dignity and promoted their independence. Staff listened to people and their relatives.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
This service was registered with us on 10 October 2020 and this is the first inspection. The last rating for the service under the previous provider was good (published on 28 March 2019).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
The inspection was prompted in part due to concerns received about staffing and due to the service not having been inspected under the new provider. A decision was made for us to inspect and examine those risks.
We have found evidence that the provider needs to make improvements. Please see the safe, and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
The provider has taken action to mitigate risks by acting on feedback from this inspection during and after the inspection. We will check the effectiveness of this when we next inspect.
We have identified breaches in relation to ineffective monitoring and auditing systems as well as the overall governance of this service at this inspection.
Please see the action we have told the provider to take at the end of this report.
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.