• Care Home
  • Care home

Archived: New Park House

Overall: Requires improvement read more about inspection ratings

Chivelston Grove, Trentham, Stoke On Trent, Staffordshire, ST4 8HN (01782) 657664

Provided and run by:
New Park House Limited

Important: The provider of this service changed. See new profile

All Inspections

11 May 2018

During a routine inspection

This inspection took place on 11 May 2018 and was unannounced. At our previous inspection in January 2018 we still had some concerns about the safety and welfare of people who used the service and we found four continued breaches of The Health and Social Care Act Regulations (Regulated Activities) Regulations 2014. The service remained in special measures. At this inspection we found that the provider had made improvements throughout and there were no breaches of regulations.

No key question is rated as inadequate and the service is therefore no longer in special measures.

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

New Park House can accommodate 95 people in three units. At the time of the inspection 21 people were using the service, some of whom were living with dementia. Only two of the three units were in use with plans to move into just one unit.

There was a registered manager in post. 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.’

We could not improve the rating of well-led from requires improvement because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

Many improvements had been made in the monitoring of the quality of the service however these checks had not always identified when the content and quality of information available to staff required improving.

Notifications were generally submitted as required by the regulations however one incident had not been notified to us, which had been referred to the local safeguarding authority.

People did not always have plans in place to ensure they had their future wishes met at the end of their life.

Further detail was needed to ensure people could effectively communicate if they were not always able to verbally make their needs known.

People were protected from abuse by staff who understood their responsibilities and could recognise different types of abuse.

Risks were assessed and planned for and we saw staff following plans in place to help keep people safe.

People were receiving their medicines as prescribed and robust systems were in place to help identify errors and take appropriate action.

There was a sufficient amount of suitably recruited staff so people did not have to wait long for support. Staff had appropriate training to support people effectively.

Infection control measures were in place to help protect people’s health and wellbeing.

Lessons were being learned as action was taken when concerns were identified to reduce the likelihood of them occurring again.

The principles of the Mental Capacity Act 2005 were being followed. People had their capacity assessed in relation to specific decisions and appropriate best interest decisions were recorded.

People had access to other health professionals and referrals for support were made when someone’s health needs had changed and guidance was followed.

People enjoyed the food and there was a choice. Those with a specialist diet were catered for appropriately.

The building was suitably adapted and people had access to equipment to assist them when needed.

Staff treated people with dignity and respect and we saw caring interactions between staff and people.

People and relatives were involved in decisions about their care where possible.

People had the opportunity to partake in a range of activities and there were further plans to enhance the activities available to people.

Complaints were recorded, investigated and responded to appropriately.

People, relatives and staff felt they could feedback and contribute to the improvement of the home. Meetings were held to encourage feedback.

An action plan was in place to try to ensure continuous improvement and there were more plans to link with organisations to improve the service and quality of care.

3 January 2018

During a routine inspection

This inspection took place on 3 January 2018 and was unannounced. At our previous inspection in August 2017 we had serious concerns about the safety and welfare of people who used the service. We found 12 breaches of The Health and Social Care Act Regulations (Regulated Activities) Regulations 2014 and took urgent enforcement action and further enforcement action instructing the provider to improve. We placed the service into special measures. At this inspection we found that the provider had made improvements throughout. However, further improvements were required. We found a continued breach of four regulations of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as there were still concerns about the safety and leadership of the service. The service will remain in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

New Park House 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.

New Park House can accommodate 95 people in three units. At the time of the inspection 31 people were using the service, some of who were living with dementia. Only two of the three units were in use.

There was a new manager in post who was yet to register with us. 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.’

People's medicines were not always managed and administered safely as advice had not been gained on the safe administration of some medicines and staff did not always have the information they needed to administer medicines safely.

People were not always safeguarded from the risk of abuse as some unexplained injuries had not been investigated or reported to the local authority for further investigation.

Some of the systems the provider had in place to monitor and improve the quality of the service had still not been effective in making the required improvements.

Staff were not always aware of and did not always follow national guidance in delivering care that met people's needs in an effective way.

The provider was not effectively following the principles of the MCA and ensuring that when people lacked the mental capacity to agree to their care they were supported to do so in their best interests.

The building and environment required improvement to meet people's needs in relation to their dementia.

People's right to confidentiality was not always respected and people were not always encouraged to be as independent as they were able.

People's diverse needs and preferences were not always identified to ensure a person centred approach to their care.

People were usually offered activities however a plan was not in place to ensure people remained active in the absence of the activity coordinator.

There were sufficient numbers of staff available to meet people's needs and reduce risks of harm.

Risks of harm to people were minimised and lessons were learned following incidents that had resulted in harm and infection control procedures were followed to prevent the spread of infection.

When people became unwell the appropriate health care support was gained in a timely manner and people were supported to eat and drink sufficient amounts to remain healthy.

People's relatives were free to visit and were involved and kept informed of people's wellbeing and people and their relatives were kept informed of any changes. There was a complaints procedure for people to use if they had concerns.

When accidents and incidents were reported to the manager action was taken to minimise the risk of it happening again.

The provider recognised the needs to improve the quality of care for people and was implementing new systems to bring about the improvements in a timely manner.

Relatives and staff respected the management and felt that improvements had been made.

10 August 2017

During a routine inspection

This inspection was undertaken on the 10, 15 and 17 August 2017 and was unannounced. We had received serious information of concern from the local authority (LA) and clinical commissioning group (CCG) following a quality monitoring visit they had undertaken. We found that the provider was in breach of several Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People using the service were experiencing inadequate standards of care that put them at risk of harm. We found that the service was not safe, effective, responsive, caring or well led. We took urgent enforcement action to suspend the provider's nursing registration and to restrict any new admissions into the service. The service has been rated as Inadequate and placed into special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

New Park House provided nursing and personal care to up to 95 people. At the time of the inspection there were 69 people using the service.

There was a new manager in post who was yet to apply to register with us. 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.

People were at serious risk of harm as staff were not meeting people's needs in a safe and consistent way. There were insufficient numbers of suitably trained staff to support people with even their basic needs. Risks of harm to people were not being assessed, monitored or minimised as action was not being taken to mitigate the risk following incident and accidents that had resulted or could result in harm to the person.

People were not being safeguarded from the risk of abuse as incidents of potential abuse had not been investigated or referred to the safeguarding authority for further investigation.

People's medicines were not being stored, managed or administered safely. People were at risk of not receiving their medication as it was intended, due to a lack of clear and comprehensive information for staff.

People did not receive health care support in a timely manner when their health care needs changed. Staff did not always follow health care advice to maintain people's health and welfare.

People's nutritional needs were not always met. Some people had insufficient amount of food and drink and this put them at risk of malnutrition and dehydration.

The principles of the Mental Capacity Act 2005 (MCA) were not always followed to ensure that when people lacked mental capacity they were supported by their representative to agree to their care, treatment and support. Some people were at risk of being restricted unlawfully.

Staff were not supported to fulfil their roles effectively and there were not enough staff for them to be able to meet people's needs. Poor staff practise was not always identified and acted upon and this put people at risk of receiving unsafe care.

People were not always treated with dignity and respect and their end of life wishes had not been planned for and acted upon.

People's right to privacy was not always upheld and their independence was not promoted. Some people spent long periods of time in bed without being given the choice or opportunity to get up.

People did not receive care that met their assessed needs and their care records did not reflect their current care needs. Details of people's preferences were not always gained or respected due to a lack of available staff. There were limited opportunities available to a small amount of people to engage in social activities. Other people were at risk of social isolation.

People knew how to complain but their complaints were not always acted upon.

There was a lack of clear leadership and clinical oversight throughout the service. The systems the provider had in place had failed to identify areas for improvement and bring about change. The management had not recognised and responded to failings within the service.

31 May 2017

During a routine inspection

This inspection took place on 31 May 2017 and was unannounced. At our previous inspection in December 2016 we had found that the service was Inadequate in the safe domain and required improvement throughout. The service had remained in special measures until the provider improved the quality of care for people. At this inspection we found that the quality of service had improved and there were no breaches of Regulations of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 however the service still requires further improvement. The service is no longer in special measures.

New Park House provides nursing and personal care for up to 95 older people. At the time of this inspection 68 people were using the service.

There were two new managers in post who were yet to register with us. 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.

Risk of harm to people were not always assessed in a timely manner. Individual care plans were not always available to support staff to care for people safely.

There were sufficient numbers of suitably trained staff however, they were not always deployed appropriately to ensure people received a positive meal time experience.

People were not always given choices about how they spent their time and encouraged to be independent. People's individual needs were not always fully assessed or their care needs met.

The management were not ensuring that all people's care needs were being assessed and met.

New staff were being employed through safe recruitment procedures to ensure they were fit and of good character to care for people.

People's medicines were stored, managed and administered in a safe way.

People were safeguarded from the risk of abuse as staff knew what to do and acted when they suspected someone had been the victim of abuse.

The principles of the Mental Capacity Act 2005 were being followed to ensure that people who lacked the mental capacity to consent to their care, treatment and support were being supported to do so in their best interests.

People were being cared for by staff who were supported and trained to fulfil their roles.

People were supported to maintain a healthy diet and they had access to a range of health care professionals if their health needs changed or they became unwell.

People's right to privacy was upheld.

Relatives and friends were free to visit people and were involved in people's care and there were a range of hobbies and entertainment for most people to participate in if they chose. However, people within the nursing unit would have benefitted from more stimulation.

The provider had a complaints procedure and they investigated and acted upon people's concerns.

There had been improvements in the systems and processes to improve the quality of service for people.

Staff felt supported and were involved in making improvements to the way they worked and to the quality of care.

19 December 2016

During a routine inspection

This inspection took place on 19 December 2016 and was unannounced. At our previous inspection in June 2016 we had judged the service as Inadequate and placed it into special measures as we had found the service was not safe, effective or well led. At this inspection we found that although some improvements had been made further improvements were required and there were continuing breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service will remain in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months.

New Park House provides nursing and personal care to up to 95 older people. At the time of this inspection 76 people were using the service.

There was a new manager in post who was yet to register with us. 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.

People's medicines were not managed safely. People did not always have their medicines at the prescribed times. Medicine records did not confirm that people had topical creams applied as prescribed. Some cream had run out of stock and some medicine was out of date and ineffective.

Risks of harm to people were not always minimised through the effective use of risk assessments. Staff required training in some areas to be able to care for people safely. People's care records were not always up to date with information to support staff to care for people.

People were not always safeguarded from abuse or the risk of abuse as unexplained injuries were not always reported and investigated.

There were sufficient number of staff deployed throughout the service. They had been recruited using safe recruitment procedures to ensure they were safe to work with people.

The provider was following the principles of the MCA 2005 to ensure that people consented to or were supported to consent to their care, treatment and support.

People's nutritional needs were being met however some people would have benefited from encouragement and support to eat. People had a choice of meals and specialist diets were catered for.

Staff were supported and received training to fulfil their role. However some staff would have benefited from training in how to support people with challenging behaviours.

People's health care needs were met. When people became unwell or their needs changed health care support was gained. People attended health appointments in the community and from visiting health care professionals.

People were offered opportunities to engage in hobbies and activities of their choice. There was a range of entertainment within the service dependent on people's individual needs. The provider had a complaints procedure and people felt they were able to complain if they needed to.

People told us they were treated with dignity and respect, however we observed that people's right to privacy was not always up held.

People told us they respected the management and that they were able to have a say in how the service was run. Improvements had been made since our last inspection however some of the systems the provider had in place to monitor and improve the service were ineffective.

7 June 2016

During a routine inspection

This inspection took place on 7 June and was unannounced. At our previous inspection in July 2015 we had concerns that people were not always supported to consent to their care and the systems the provider had in place to monitor the quality of the service were ineffective. At this inspection we found that no improvements had been made and care being delivered was not safe, effective or well led. We have rated this service as Inadequate and placed the service into special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months.

New Park House provides nursing and personal care to up to 95 older people. At the time of this inspection 86 people were using the service.

There was a new manager in post who was yet to register with us. 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.

The provider was not protecting people from the risk of harm through neglect as they did not ensure that there were sufficient staff delivering care that were trained and competent. Some staff were delivering care they were not trained to do.

People's medicines were not managed safely. People were not always given the correct dose of their prescribed medicine at the prescribed times and some people had not been administered their medicine as the provider had not ensured sufficient stock was available at all times.

The provider did not consistently follow the principles of the MCA 2005 to ensure that people consented to or were supported to consent to their care, treatment and support.

Systems the provider had in place to monitor and improve the quality of the service were ineffective. Records were inconsistent and disorganised. Audits had not identified the shortfalls in the care being delivered.

People did not always receive care that met their individual needs and preferences .Some people were not engaged or stimulated by activities or their surroundings. Some people sat for long periods of time with no interactions.

People were not always treated with dignity and respect and their right to privacy was not always upheld. People's choices were not always respected as they were not always able to go where they wanted to go when they wanted to.

People's nutritional needs were not always met and health care support was not always gained in a timely manner. People had lost weight and health care advice had not been sought.

There was a complaints procedure and people knew how to use it. People and relatives we spoke with told us that the new manager and staff were kind and approachable.

To Be Confirmed

During a routine inspection

The inspection took place over two days on 8 and 16 July 2015 and was unannounced.

New Park House provides nursing and personal care to up to 95 older people. People with nursing care needs are accommodated on the first floor and people with personal care needs live on the ground floor.

A registered manager was in post. 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.

People’s risks were assessed in a way that kept them safe from the risk of harm. This included people's risks of developing skin damage. Records in place supported staff with the management, care and treatment of pressure ulcers. 

People who used the service received their medicines safely. Systems were in place that ensured people were protected from risks associated with medicines management.

We found that there were enough suitably qualified staff available to meet people’s care needs. Staff were trained to carry out their role and the provider had plans in place for updates and refresher training. The provider had safe recruitment procedures that ensured people were supported by suitable staff.

The Mental Capacity Act (MCA) 2005 and the DoLS set out the requirements that ensure where appropriate, decisions are made in people’s best interests when they are unable to do this for themselves. Not everyone who required a mental capacity assessment had received this, although meetings had been held and best interest decisions made where required.  

People’s health needs were monitored but referrals to health care professionals had not always been made in a timely way when people’s health care needs changed. Records did not always support staff to make appropriate referrals.

People had enough to eat and drink and were supported with their nutritional needs including receiving nutritional supplements where required. Records were kept to demonstrate people's food and drink intake where required.

People told us that staff were kind and caring. Staff treated people with respect and ensured their privacy and dignity was upheld.

There was an activities programme and people had opportunities to be involved in hobbies and interests that were important to them.

The provider had a complaints procedure available for people who used the service and complaints were appropriately managed.

Staff felt able to raise concerns about poor practice knowing that they would be supported to do so.

Staff felt supported by the registered manager but some staff felt that more direct support and management on the floor was required in some areas of the home.

The registered manager had systems in place to monitor the service and we saw that whilst some improvements had been made when identified, others had not been picked up by the system.

5 June 2013

During a routine inspection

This was a follow up inspection of New Park House as a result of issues which we identified when we inspected the home in January 2013. During the earlier inspection we found that although there were systems in place to collect and analyse complaints and concerns of people who used the service. There was no evidence to show that the service was responding to the issues.

In addition to following up the previous concern we inspected other aspects of care while we were at the home. We used the services of an expert by experience to help us judge the quality of care.

We saw that people were treated with respect by the staff who cared for them. One person said, "I can't complain. It's very nice here'. Another person said, 'They listen to me and treat me okay'.

We found that care records we checked were personalised and contained assessments and information to enable staff to keep people safe and provide them with appropriate care.

People told us they would tell staff if they were worried or afraid of anything. Staff were trained in adult safeguarding and knew how to support the people they cared for.

As a result of New Park House implementing their action plan we saw that systems were in place to ensure problems were identified, analysed and addressed.

17 January 2013

During an inspection looking at part of the service

At the last follow up inspection in September 2012 we identified areas where the provider was not meeting all of the essential standards of quality and safety. The provider sent us an action plan to tell us what they would do to become compliant with the regulations.

The care that people received had improved. People we spoke with were happy with the care that they received. The care records we viewed showed that the plans of support had improved and they were available for all staff members to access.

The provider had made improvements with the way they managed the medication of people who used the service. Regular checks were carried out to ensure that people were receiving their medication in a safe manner and protected from the risk of harm.

The provider had made improvements to the way they reviewed and audited the care provided to people who used the service. However, there were still some improvements needed to ensure that the care received was monitored and actions that were completed were documented.

11 September 2012

During an inspection looking at part of the service

At the last inspection in May 2012 we identified areas where the provider was not meeting the essential standards of quality and safety. The provider sent us an action plan to tell us how it was going to become compliant with the regulations.

The care people received had improved. People were referred for health care support. The care of people with pressure ulcers had improved. People were having their weight checked regularly and actions taken to seek medical advice when there were significant weight changes. Plans were in place to improve the information in plans of care to make them more specific to people and to make them more available to care workers. However there were a large number of plans that still needed to be developed to provide this information.

The provider had made improvements in the way it managed safeguarding incidents. People were better protected because staff were aware of signs of abuse and knew how to act on any concerns they had.

The provider had made improvements to the way it managed people's medication, although further procedures were needed to make sure that people always had their medication as prescribed.

The provider had some systems in place to listen to the views of people and to monitor and review people's care. However some of the systems were not yet fully in place and there remained some areas that were not being fully monitored.

4 May 2012

During an inspection in response to concerns

We carried out this inspection as part of our schedule of inspections and because we had received concerns about the service. We wanted to see what life was like for the people who lived in the home. We also wanted to see whether the service had made any improvements since we last visited.

Before our visit we contacted other people who may have had an interest in the service. We had received some concerns about the service from the local authority. They had received a number of safeguarding allegation referrals about the service. Safeguarding referrals can be made by anyone (including the service themselves) when it is thought that people may be placed at risk of abuse or if there is poor practice at the home. There had also been some delays by the service in reporting and referring safeguarding to the local authority and to CQC. The local authority was in the process of investigating these concerns and was also reviewing the care of the people they funded at the service.

During our visit to the service we spoke with eight care staff, two nurses, the manager and the compliance manager. We also spoke with a total of fifteen people who lived in the home and five relatives.

The visit was unannounced. This means that the service did not know that we were coming. The manager was not on duty at the start of the inspection visit but she joined us and assisted us throughout our inspection. We were also assisted throughout our visit by the compliance manager and the training manager.

People were complimentary about the staff who looked after them and said that they were 'kind' and looked after them well. One person said that the staff were 'marvelous' and 'nothing is too much trouble for them'. We observed staff interacting positively with people.

People had a plan of care in place managed on a computerised system. However not all staff felt that the care plans were easily accessible to them. Plans were not very person centred and could not demonstrate that all aspects of people's individual circumstances had been considered.

Some nurses were not clear about procedures around palliative care. This meant that people did not always receive the right care at the right time.

Daily care records were in place for each person but these had not always been completed. This meant that it was difficult to monitor and assess people's fluid intake.

Staff we spoke with told us that they had received induction training and there was ongoing mandatory training. This helped to ensure that staff had the basic knowledge and skills to meet the needs of people who used the service.

The service was in the process of recruiting staff and had endured a shortage of permanent staff over a period of time. This had resulted in the service regularly using a high number of agency staff. There had been inconsistencies in the delivery of care and mistakes had been made.

There had been mistakes made with the management and administration of medication. Although a new system of medication management had been introduced mistakes had continued to happen. This meant that people had not received their medication as per their prescription.

There had been ineffective quality monitoring of the service. The service had audits and monitoring in place but these failed to recognise failings and generate improvements.

The service had previously been at the centre of a large scale investigation. There was evidence that the service was not learning from incidents and investigations that took place then. Appropriate changes had not been implemented.