Park View Care Centre

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 that 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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accident and incidents were recorded by staff. These included when people had fallen, were found to have an unexplained bruise, or had experienced periods of distressed behaviour. Accidents and incidents were closely monitored and analysed to check for trends and causes to learn lessons and prevent future occurrences.

Appropriate action was taken following accidents or incidents, for example, people who had fallen regularly had been referred to a healthcare professional such as occupational therapy or the falls team. People who had been distressed were referred to the GP for checks. Care plans and risk assessments had been reviewed and updated following an incident to prevent further re-occurrence.

The registered manager instilled a culture of learning lessons within the staff team. They produced a regular ‘lessons learnt newsletter’ to share with staff. Subjects included how to make sure 4 weekly care plan reviews were thorough and meaningful. This included making sure they incorporated accidents or incidents from the previous month into the care plan to ensure an accurate and meaningful reflection of people’s up to date needs.
A relative told us, “One early success was to reduce regular falls, cured with a new pair of shoes that fitted”. Another relative said, “There’s a sensor mat now and they keep a discrete eye on him”.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

An initial assessment was completed with people before they moved into the service to support their safety and transition. The registered manager told us only they or the clinical lead nurse completed assessments to make sure they were able to meet the needs of each person, such as the correct staffing levels with the skills and experience they would need to provide safe care. They also liaised with other relevant partners, such as the hospital where they were an in-patient, family members or a current care provider to support a smooth move.
Relatives told us they were involved in providing personal information about their loved one to support the initial assessment and ongoing review. A relative said, “An assessment was completed and we have been involved in discussions about (their) changing care since then”.

People’s care plans provided sufficient detail about each element of their care and how they liked things done, what they could do independently and what they needed help with. Care plans were reviewed regularly so crucial information was up to date. This meant if they needed to go into hospital or move to another care facility, their health and care requirements could be shared to aid their continuing care.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their relatives told us they felt safe living at Park View Care Centre. Comments included, “I totally feel safe, oh yes, I feel safe”; “The staff are marvellous, he’s very fond of them and they help him cope with some serious challenges in his life”; “Amazing. Can’t fault them” and “There’s always someone (staff) around and the manager is rarely far away”.

Incidents had been appropriately referred to the local authority in accordance with safeguarding vulnerable adults’ protocols. Staff had raised concerns when they should, and these had been raised externally when necessary. Investigations had been undertaken to understand what had happened, take action where necessary and determine what needed to happen to learn lessons.

Where relevant, a Deprivation of Liberty Safeguards (DoLS) application had been made when people had been assessed as lacking the capacity to consent to their care and treatment.

The provider did not always work well with people to understand and manage risks. Records did not always provide guidance for staff to ensure safety and mitigate individual risks.

At the last inspection the provider had been in breach of regulation in relation to how people’s individual risks were assessed and mitigated. At this inspection, although there were some minor areas the provider could make further improvements, we were satisfied they were no longer in breach of regulation. The registered manager had taken up their post since the last inspection and had spent time making changes and improvements across the service.

People did not always have individual risk assessments in place to provide the necessary guidance to enable care staff to provide safe care and recognise signs of deterioration when delivering care. One person had recently experienced seizures. A risk assessment was not in place to set out the risks associated with this, what staff should look out for and what they should do in the event of the person having a seizure. The clinical lead told us the seizures had happened in hospital and were not thought to be an ongoing condition, and they had not been diagnosed with epilepsy. However, they accepted the person had seizures and been prescribed medication to reduce the risk of further seizures and it had therefore not been discounted, so was a continued health risk. The clinical lead immediately developed a risk assessment to describe the risks to the person and to provide guidance for staff to mitigate these risks.

People who had a catheter in place had individual risk assessments to support safe care to avoid the risk of complications such as infection, or the catheter becoming blocked or trapped. One person was able to complete some elements of their catheter care, such as emptying the urine bag and this was clearly documented. Staff were guided to check regularly that the person had not forgotten, so they could be prompted if they did, to avoid accidents or complications. The record confirmed how often the catheter should be changed by a nurse, and the date this was next due.
A relative said, “They’ve worked wonders – first, sorting out health issues and now she’s drinking and eating properly her old list of risks has shrunk dramatically”.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The building was purpose built and provided safe accommodation for people to live in. The communal areas such as corridors, lounges and dining areas were clutter free, so people had safe access that did not compromise their safety and risk of falls.
The premises were well presented, with bedrooms, bathrooms and communal areas kept to a high standard. Communal lounges were available for people to sit in, as well as small seating areas located in corridors. People’s rooms were personalised and homely, supporting their well-being and comfort. The overall atmosphere throughout the home was quiet, calm and welcoming.
A relative told us, “From my first visit to check the service, there was something about it when you walk in, I knew this was the right place for (my relative)”.

Cupboards were locked where cleaning products or equipment that may be a risk to people’s safety were stored. The premises were well maintained and regularly checked for risks, including fire safety, and equipment was serviced at appropriate intervals.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff to meet people’s needs. There was a full staff team of nurses and carers, which meant people were supported by staff who were familiar and knew them well. Agency staff were used in a limited capacity only, such as short notice absence or when more than 1 staff member was unavailable for their shift.
People and their relatives told us they thought there were sufficient staff and staff were very attentive, they did not need to wait long to get the help they needed. Staff also told us they had enough staff to meet people’s needs and did not feel under pressure to rush people when providing their care.

Staff received the training they needed. There was a comprehensive list of training available for staff to complete, including the specific needs of people living in the service, such as catheter care and diabetes. Staff received regular supervision to assess and provide feedback on their performance and look at development opportunities available.

Staff had been recruited safely; the required checks had been completed to make sure staff were of good character.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and generally free from odours. People told us the home was always kept clean. Comments included, “His room is always clean and tidy, the same with the whole home” and “The whole place is very, very clean and no urine smells. It’s hard wood floors throughout so no carpets to trip over. The cleaning lady is marvellous. The other thing is that there’s no clutter so chances of tripping over things are slight”.

Staff had access to Personal Protective Equipment (PPE) when needed to support the prevention of infection spreading. Staff had received training to increase their understanding and put this into practice. People and relatives confirmed staff wore PPE when they needed to.
Regular audits were undertaken to check the effectiveness of infection control procedures. Action was taken when areas to improve were found.
 

The provider did not always make sure that medicines and treatments were safe and records were accurate.

People’s medicines were not always managed safely. There were some contradictions between the storage advice on the prescription labels of some medicines, and the advice within the patient advice leaflet. There had been no impact on people as the medicine was stored correctly and there was a permanent and stable team of staff administering the medicines who were aware of the correct storage instructions when we asked them. However, there was a potential risk the medicines could have been stored incorrectly (as per the prescription label) if agency staff or new staff were administering medicines, which would have impacted the efficacy of the medicine, posing a serious risk to the person. We raised this with the registered manager who took immediate action to contact the pharmacy to amend the prescription labels.

Other areas of medicines administration were safely managed. Where people had as and when necessary (PRN) medicines prescribed, guidance was in place for staff in relation to why the medicine was prescribed, when to give it and the safe dosage. Staff who had responsibility for administering people’s medicines had the appropriate training and competency checks to make sure people received their medicines safely.