Park View Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to governance. 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 governance at the service.

This service scored 43 (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 have a clear or shared vision, strategy, or culture based on transparency, equity, equality, human rights, diversity, inclusion, or meaningful engagement. They did not always demonstrate a good understanding of the challenges faced by people or their individual needs. For example, the management of the service had been inconsistent since our last inspection in 2022. This lack of stability affected how well staff worked together. Frequent management changes added to the lack of clear communication and standards and expectations. Feedback from staff about the leadership and culture within the home was mixed. One staff member told us, “We have new management, we’ve had a few. I feel like every time you go to [management] with a problem; there’s never an answer. Jobs that should be completed by managers are being delegated to us, adding to our workload and making it unmanageable.” However, another staff member shared, “We can approach the manager any time, she seems lovely.”

Whilst leaders were visible within the service, they had not always identified the issues we found during this assessment. There had been a period of change and inconsistent management prior to our visit. A new home manager and deputy manager had recently been appointed and were being supported by the regional management team. There were ongoing concerns and recurring themes identified during our previous inspection. Such as governance systems needed to be embedded and the need to demonstrate people were given the opportunity to consent to some decisions as well as medication management. Some of the concerns we found had already been highlighted through the provider’s internal audits but had not been addressed. Staff and relatives described leaders as friendly; however, one relative told us they had not yet met the new manager and would welcome the opportunity to do so.

Where we identified areas for improvement, the management team were receptive to feedback and, where possible, took prompt action.

Staff did not always feel they could speak up and their voice would be heard. For example, staff did not receive regular supervision to promote opportunities to speak up if needed. We received mixed feedback about staff speaking up. Comments included, “I feel uncomfortable bringing things up if they’re not going to be resolved” and “Yes, I am able to speak up. I’d go to the senior or the nurse that’s on shift that day and speak to them.” Information on how staff could raise concerns such as the whistle blowing policy was available.

Although the provider valued diversity in their workforce. They did not always work towards an inclusive and fair culture for people who worked for them. For example, supervision records showed a member of staff wanted to take leave which they were entitled to but this was met with conditions such as if they are short staffed, the staff member would be required to work. Some staff had raised concerns with the provider about staffing levels and how they were struggling to fulfil their roles, but felt management were unsupportive regarding these concerns. A staff member told us, “They [Management] are constantly pushing overtime onto staff. A message was put out on our WhatsApp group asking if anyone wants to do overtime and when nobody responded straight away, [Management] sent a message saying, ‘Can no-one read?’.”

The provider did not have clear roles, responsibilities, or effective systems of accountability and governance. They did not always use reliable information about risk, performance, and outcomes to make improvements or share it appropriately when needed. For example, the provider’s quality assurance systems were not robust and had failed to identify the concerns found during this assessment. There was a lack of management oversight in key areas, including staff training, supervision and performance. Care plan audits highlighted some people’s care plans lacked personalised information, despite this, no action had been taken to make the improvements. Managers daily walkarounds were not effective in identifying and mitigating areas of risk.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Some incidents had not been reported to the local authority safeguarding team and CQC. The manager told us they reviewed incidents; however, an incident involving an allegation of abuse had not been followed through and reported to the relevant bodies. Visiting health and social care professionals provided mixed feedback about their experience with the provider. Comments included, “Issues are being brought to multi-disciplinary meetings [MDT], for instance residents unwell over the weekend may be left until the next meeting. Staff have been challenged on this and advised to use proper channels at the time of the issue.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering good outcomes and quality of life for people. They did not always actively contribute to safe, effective practice and research. We identified incidents where the manager was unaware of guidance and regulation with regards to the mental capacity act (2005) and knowledge about dealing with safeguarding concerns. The provider acknowledged improvements were needed to make sure people always received high quality care and support. Internal and external audits had not led to learning or improvements being made in a timely way. One member of staff told us, “They have put things in place and acted on the concerns as far as I’m aware of but more needs to be done.”