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Inspection Summary

Overall summary & rating

Requires improvement

Updated 30 November 2018

This inspection took place on 23 October 2018 and was unannounced.

Park Grove is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Park Grove is registered to provide accommodation for up to 32 people who require nursing or personal care. All accommodation at the service is provided on a single room basis, although there is one double room available for a couple or anyone who wishes to share. Facilities at the service include several communal lounge areas, a dining room and safe accessible garden areas. There were 25 people who lived at the service at the time of the inspection.

There was a new manager who had applied to become a registered manager. The previous registered manager de-registered in September 2018 after terminating their employment at Park Grove in August 2018. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection we found shortfalls in relation to environment safety, seeking consent, staff training and supervision and arrangements for checking the quality of the care. These were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to: safe care and treatment, need for consent, staffing and good governance. We also found one breach of the Care Quality Commission (Registration) Regulations 2009, in relation to notification of other incidents. You can see what action we told the provider to take at the back of the full version of the report.

Our last inspection of Park Grove was carried out 06 January 2016. At that time, we rated the service as overall 'good' with the responsive domain being 'requires improvement'. There were no breaches of the regulations at that time. At this inspection the rating had deteriorated to overall 'requires improvement'.

We found that the service had procedures in place for protecting people from abuse, neglect and discrimination. However, we also found that staff had not received training in safeguarding adults that was in line with the local safeguarding authority alert processes. This meant that the provider had not made sure staff understood how make a safeguarding alert and kept them up to date with changing legislation and best practice principles.

The provider followed safe recruitment processes to ensure that new staff were of good character before employed.

We looked at accident and incident records and found that people were not always safeguarded following an unwitnessed fall. The manager showed us a new system they were introducing for identification, review and monitoring of accidents and incidents.

We found that people who lived at the service were accurately risk assessed and care plans had been formulated to show how people would be protected against identified risk. The service was adequately staffed and people told us that they felt safe and well supported.

We looked at the environmental risk assessments and maintenance records and found a clear audit trail had not been sustained. We discussed this with the provider who told us that improved record keeping would be immediately introduced. We saw that the environment was safe and clean. We checked how the provider protected people from the risk of exposure to fire and how they planned contingency strategies in the event of an emergency evacuation. Our checks showed that the provider did not have robust planning in place for emergency evacuation and some routine fire prevention checks had not been recorded.

We found that people received their medicines in a safe and proper

Inspection areas


Requires improvement

Updated 30 November 2018

The service was not consistently safe.

Medicines management was not always person centred and systems for managing medicines were not always safe.

Processes were not always in place to help maintain a safe environment for people who lived at the service, staff and visitors.

The service protected people from abuse, neglect and discrimination, however staff did not always understand what constituted to a safeguarding alert.

Staff recruitment procedures protected people who lived at the service.

The service made sure there were sufficient numbers of staff to support people to stay safe and meet their needs.

Risks to people’s individual safety and well-being were assessed and managed.

People were protected by the prevention and control of infection.


Requires improvement

Updated 30 November 2018

People’s consent to care and treatment was not always sought in line with legislation and guidance including seeking consent.

The service did not fully ensure that staff had the skills, knowledge and experience to deliver effective care and support.

People’s needs and choices were assessed and their care and support delivered to achieve effective outcomes.

People had access to healthcare services and were supported to eat and drink enough to maintain a balanced diet.

The service did not fully ensure that people's needs who lived with cognitive or visual impairment had been met by the adaptation and design of premises.



Updated 30 November 2018

The service was caring.

People were treated with kindness, respect and compassion and that they were given emotional support when needed.

Improvements were required to demonstrate how people were supported to express their views and be actively involved in making decisions about their care, support and treatment as far as possible.

The service empowered and enabled people to be independent. People's privacy was respected and promoted.


Requires improvement

Updated 30 November 2018

The service was not consistently responsive.

People received personalised care that was responsive to their needs.

People’s concerns and complaints were listened and responded to and used to improve the quality of care.

People were supported to engage in activities within the local community and pursue their hobbies and interests.

People were supported at the end of their life to have a comfortable, dignified and pain-free death.

Information was not always provided in an accessible manner to people with sensory impairment.


Requires improvement

Updated 30 November 2018

The service was not consistently well led.

Policies for quality assurance were in place however they were not always effective to monitor the quality of the care provided.

Management arrangements had not always been consistent and this meant shortfalls were not always identified.

There was a new manager who had started to implement required improvements however this was at an early stage.

The service worked in partnership with other agencies. People who lived at the service, their representatives and staff were consulted on their experiences and involved in future plans.