Park View Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the service remained in breach of this regulation. The provider was in breach of legal regulation in relation to safe care and treatment and staffing.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always learn lessons to continually identify and embed good practice. For example, concerns regarding consent and records identified at the last inspection had not been fully resolved. The system in place for recording and analysing incidents was not always clear how lessons were learnt from these and how these could be used to drive improvements for people. An incident which should have been looked into was missed and steps were not taken to keep other people safe.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services. For example, initial assessments, lacked information about people’s needs to ensure a robust care plan. Staff did not always follow instructions quickly from other healthcare partners. A healthcare professional said, “There have been a few times recently when changes to medication or treatment plans weren’t shared with staff, causing delays in treatment.” Another professional commented, “Residents have been referred to district nurses who are paying for nursing care and sometimes staff will not know who is in a residential bed or a nursing bed.” The provider assured us they were working hard to ensure a smooth transition of information between services.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve it. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. For example, one person raised concerns with the manager about an allegation of abuse, however, this was not escalated to the local authority safeguarding team for independent review. Moreover, two people had an altercation, this was not reported to the local authority nor other relevant bodies.

Staff had completed training in safeguarding and understood their responsibilities in relation to keeping people safe and felt confident to raise these with the manager. People told us they felt safe. One relative told us, “[Name] is safe here, and she has some friends here. There are codes to get in and out, so she is safe.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. For example, a person who was at risk of a mental health condition, their care plan was not detailed to identify signs and symptoms and how best to support that person. We found some people were using each other’s wheelchairs and hoist slings. A hoist sling is a piece of equipment used to safely lift and move a person from one place to another, such as from a bed to a chair. These slings were individually prescribed to suit each person’s size, weight, and needs, ensuring transfers were safe and comfortable. This placed people at risk of cross contamination and or injury.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Some routine monitoring of environmental risks were not being undertaken appropriately. For example, large amounts of people’s continence equipment were stored in their bedroom and bathrooms hindering ability to move freely or perform tasks in a safe way. When we identified these concerns the management team acted swiftly to address these concerns.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Although the provider had recruited people safely, they did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care which met people’s individual needs. For example, staff did not always receive training, supervision and induction appropriate and relevant to their role, or have their competencies assessed in line with current best practice guidance. A member of staff told us, “We had an emergency the other day and they sent someone from another floor. The manager was just sitting in the office when they could’ve been helping us. I’ve been working on a dementia unit when I’m not trained in this specialty. They need nurses, I can’t do dressings, I can’t make clinical decisions like insulins.”

We observed in some areas of the home; staff were not readily available to support people. For instance, a person sat in the lounge who had been waiting and was calling out for a ‘nurse’ asked us to locate a staff member, as they had been waiting for a long time for assistance with personal care. A relative told us, “Sometimes there are no members of staff in the lounge and there may be people who want to go to the toilet and there is no one around, they have lost a lot of staff. They have changed managers a lot and they don’t come around to see you.” This was supported by feedback we received from other healthcare professionals. Comments included, “There are not sufficient staff to appropriately manage dementia residents, however, Park View will accept these patients. There have been a few incidents as a result of inadequate staffing, such as frequent falls and patients wandering into other patient’s rooms.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. For example, the premises and equipment were not kept clean and hygienic. There was an unpleasant odour in parts of the home and some surfaces, people’s bedding, bathrooms and equipment such as commodes were dirty. Although staff had completed their training in infection prevention and control, they did not follow safe infection prevention and control practices; they did not use PPE when handling soiled items. The manager assured us they would address this. immediately.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Prescribed topical creams were not stored securely and were kept in people’s wardrobes or bathrooms. Some topical creams with an expiry date once opened did not display the date of opening to ensure it remained safe for use. Some people did not receive their prescribed medicines at the correct times. This included time-critical medicines that need to be given at specific times to work properly. Delays in giving these medicines can make symptoms worse or expose people to potential side effects, and risk of harm. Some people were not administered their prescribed medicines at the right time, this included time critical medicines to be given at a certain time to make sure they were effective as this can worsen symptoms. The provider assured us they had identified this in their quality assurance and were providing staff with further training in the safe management of medicines.