Turning Point - Parkview

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• 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 good. At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to safe care and treatment, safeguarding, safe premises and staffing.

This service scored 41 (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 to managers appropriately. Systems were in place to record incidents and to analyse these for emerging themes and patterns. Learning from incidents was shared with the staff team through team meetings and individual supervision to support improvements. Staff and managers communicated daily through shift handovers and an online platform to ensure all were kept up to date.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did, however, make sure there was continuity of care when people moved between different services. The provider had not consistently advocated for a person to ensure appropriate involvement from other services. This had contributed to a lack of action being taken to support them effectively. However, the new team leader had recently begun working with the person more proactively resulting in more positive outcomes.

Several people were supported to attend a day service and staff confirmed they regularly shared information with staff there. During a recent hospital admission, a person was supported well by staff, who shared relevant information with the hospital and stayed with the person during the day to ensure their needs were understood and met.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free of avoidable harm and neglect. The provider had not made safeguarding referrals as required. We reviewed records and found staff documented unexplained injuries such as bruises and informed the team leader. However, these incidents had not always been reported to the local authority or CQC as required. We received mixed feedback from relatives about whether people were safe from avoidable harm. Although a relative told us “I have no qualms about that.”, another relative told us they had concerns about unexplained injuries their family member had sustained, saying, “Quite a lot of things have happened to [Family Member] since [they] moved in there – been hurt, injured.” Staff completed training in Safeguarding and understood their responsibility to report any concerns although we observed poor care that had not been recognised as a safeguarding concern. Staff did not have good understanding about who to report concerns to outside of the organisation.

Following our assessment, the provider had implemented a concise fact sheet for how to make a safeguarding referral and a local procedure for staff to follow.

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. Risk assessments were not consistently robust or detailed enough to guide staff in delivering safe care. For example, a person at risk of choking had no clear guidance for staff beyond calling an ambulance and a person with a severe allergy lacked a detailed plan to ensure safe support. A person beginning to mobilise again had an incomplete mobility risk assessment, offering insufficient direction for staff. The provider confirmed a referral had since been made to support the development of a robust risk assessment for this person. Poor moving and handling practices placed people and staff at risk of harm. We observed staff dragging a person backwards in their chair before assisting them to stand. This posed a risk of the person falling and potential injury to staff. Following our assessment, the provider confirmed staff had since completed face to face training in safe moving and handling. Some people had support plans to manage distress. We found limited evidence these were followed by staff and a lack of understanding of what to document and why. After this assessment, the provider confirmed their in-house positive behaviour support lead was going to work with staff to develop their skills in this area.

Following our assessment, the provider completed a plan to guide staff in action to take if the person had an allergic reaction.

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.

The provider was aware of the need for repairs and maintenance; however, progress had been slow. For example, during our initial site visit on 23 July 2025 the shower room door was missing This concern was first documented by staff in the communication log on 5 July 2025. No remedial action had been taken when we visited on 23 July 2025, and staff were using a portable screen, which did not offer adequate privacy. During our 2nd site visit on 12 August we saw the provider had replaced the shower room door.

In 1 room, a wall-mounted wardrobe was coming loose, posing a risk of entrapment. Additionally, the laundry door and 2 cupboards containing hazardous substances were left unlocked, exposing individuals to potential harm.

The garden was a pleasant space for people to use. However, an old door, a bin containing paper and a shelving unit left out there detracted from this. These, along with a trailing hose across the pathway presented a risk to people using this space.

Some boxes containing paper stored in the hallway were a fire risk, as were the similar contents of an unused bedroom. A recent fire drill was the first in over two years. Staff were unfamiliar with people’s evacuation plans and in some cases were not aware that such plans were in place or where to find them. Some staff were unable to identify fire exits and assembly points. This put both people and staff at risk in the event of a fire.

The provider did not make sure there were always enough qualified, skilled and experienced staff. They had not always made sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There were gaps in staff skills and knowledge, particularly about how to communicate and engage effectively with people, and allergy awareness in relation to the administration of emergency medicine to 1 person. The provider was beginning to address this, and we saw some supervision meetings and practice observations had taken place. The locality manager told us of planned training in relation to positive engagement, person-centred care and the emergency medicine. However, this had not happened yet and meant people were at risk of harm and of not having their social and emotional needs met.

Although there were enough staff to support people safely, there were not always enough to support them to take part in activities that met their individual needs. Relatives told us this was an ongoing concern. Staff said they could support people safely with current numbers of staff, but 1 more would have made it possible to provide more individualised and stimulating support. Staff recruitment was carried out safely and appropriate checks were made to make sure only suitable staff were employed.

The provider did not always assess or manage the risk of infection. Some areas of the service were not in a good state of repair which increased the risk of the spread of infection. For example, damaged laminate on kitchen work tops and bedroom vanity units. Flooring was worn and damaged in some places which also increased the risk. The provider had been slow to address these repairs. However, after this assessment, the provider confirmed the flooring in the kitchen and bathrooms had been replaced.

Although the home was mostly visibly clean, some corners, skirting and air vents were stained or dirty. Where notices had been removed from walls and doors, sticky tack and residue remained which increased the risk of the spread of infection. Some food was out of date and 1 kitchen cupboard used to store food items was very warm due to heat transmitted from a kitchen appliance. These issues could have put people at risk of eating food that was unsafe.

Staff had completed training in infection prevention and control (IPC) and we saw they wore appropriate PPE (personal protective equipment) when supporting people.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. A person was prescribed emergency medicine for a potentially life-threatening incident. The care plan did not contain an emergency treatment protocol regarding the medical condition or a risk assessment, and no staff members had up to date training in the administration of the medicine. This put the resident at severe risk in the event of an incident. Following our visit, the provider arranged for staff training on site. Staff were unable to find risk assessments for prescribed emollients during our visit. This posed a potential safety risk, as emollients can be flammable and increase the risk of fire-related harm. There was no record of advice sought or best interest decisions being made when staff administered medicine in food to make it easier for people to swallow. This method of administration was not recorded on their Medicine Administration Records (MAR). Although one person had a best interest decision meeting in 2020 for covert medicines, it had not been reviewed to include their current medicines. We were therefore not assured people were receiving medicines in line with their assessed needs and preferences.

The provider had not ensured people’s medicines were stored safely. We found some out of date medicines in the fridge and some medicines refrigerated which did not need to be. Room temperatures were not recorded, and fridge temperatures were not available. Staff confirmed they did not keep records from the previous month.

The provider had not ensured people’s medicines records were documented correctly. Staff had not signed MAR charts to indicate who had administered the medicines; this did not follow national guidance. We found medicine for 1 person was not recorded on their MAR. Staff did not have people’s current prescriptions; this meant staff were reconciling medicines from memory. The provider addressed this with the pharmacy and copies would be provided.