Park View

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 good. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment, the safe management of medicines and staffing.

This service scored 38 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems were in place for staff to document incidents and accidents and these were individually reviewed by the service manager. However, because these were not documented on the provider’s electronic system, they were not being monitored to make sure action was taken to remedy the situation, prevent further occurrences and ensure improvement were made as a result.

For example, 1 person experienced 3 incidents harm resulting from undertaking a personal care related routine independently. This pattern had not been identified, and no action had been taken to mitigate further risk of injury to the person.

The lack of thorough analysis of incidents placed people at risk of being exposed to re-occurring risks.

Lessons learnt was a standard agenda in team meetings, and we saw some evidence recorded in team meetings minutes of conversations held, for example in relation to reporting safeguarding concerns.

The provider mostly worked 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 not always make sure there was continuity of care, including when people moved between different services.

Health action plans or hospital passports were either not in place or had not been reviewed for a significant time. This meant peoples individual needs may not be safely met if they were required care in an alternative setting such as a hospital.

Consistent and robust records in relation to service users’ medical appointments were not always maintained. For example, for one person, we saw a referral had been made a year previously for specialist medical support, however there was no record of this having been followed up after the person was placed on a waiting list. There was a record of them being schedule for a medical investigation, however, the record showed this had been re-scheduled. There was no follow up record of the person attending the subsequent appointment or the outcome of this. The failure to follow up on medical referrals or the outcome of investigation placed people at risk of not having their health needs met in a timely manner.

Feedback from health and social care professionals was mostly positive in relation to their working relationship with the service. One health professional shared their positive experience of visiting one person to review their medicines. Another health professional told us they sometimes have difficulties contacting the home to plan medical reviews.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Staff employed by the service received safeguarding training. The service was reliant on the use of agency staff on a regular, ongoing basis. Up to date records of safeguarding training for the agency staff were not always held by the service to assure themselves that this training had been updated by the agency provider. Staff had knowledge of the principles [JK1]of safeguarding, however they could not all describe what safeguarding meant.

The service maintained a record of safeguarding concerns reported by staff. However, there was no information of any actions taken or why these had not been reported outside the service. Some incidents dating back several months had not been fully reviewed internally and others were recorded for ‘advice only’ with no actions taken. The failure to review and take any necessary action in response to safeguarding concerns in a prompt and timely manner meant people remained at risk.

One care plan included information about restrictive practices. This had not been identified by the provider and action was only taken after we raised this with them.

During our assessment, we made a safeguarding referral to the local authority for 2 people.

Following our feedback, the concerns we identified were escalated to the provider’s safeguarding lead who agreed actions they will be taking. We were unable to assess the implementation and effectiveness of these proposed actions during the assessment.

The service did not always work within the principles of the Mental Capacity Act 2005 (MCA).

The service manager has oversight of Deprivation of Liberty Safeguards (DoLS) authorisations.

The service was undertaking a restrictive practices audit for each person. However, this had not identified that the principles of the MCA were not being met.

People did not share any concerns about their safety and appeared relaxed around staff. People’s relatives and representatives told us that people felt safe living at the service. One relative told us; “Never had any concerns about his safety there”.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people were not always fully assessed and mitigated. Where these were, there was no evidence of review for a significant amount of time. For example, where risks assessments were in place, these had not been reviewed yearly, in line with the provider policy to ensure that the assessment and mitigation was still appropriate for the person placing the person at risk of unsafe support.

We identified risks for people which had not been assessed and mitigated, for example in relation to the use of equipment, finance, use of technology and personal care tasks.

Positive Behaviour Support plans were in place to guide staff on how to support people at times of experiencing anxious behaviour. These plans were not regularly reviewed and updated in line with the provider’s policy. We found discrepancies between the current support guidelines and the information provided to staff in these plans.

People had Personal Emergency Evacuation Plans (PEEP) in place to inform staff how to support people in case of an emergency such as a fire. However, these had not been reviewed for a significant period of time. For example, for one person, this was created in 2020 and there was no evidence this had been reviewed to ensure the information was still relevant in order for staff to support the person safely.

Staff were aware of people’s risk, however they were reliant on care documentation which in the main had not been reviewed in line with the provider’s policy and for a significant amount of time. The service was reliant on the consistent use of agency staff to cover vacancies and absence. This increased the risk to people as agency staff and new staff did not have access to up-to-date information related to people’s risks and how to safely support them.

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

Risks related to the environment were being managed; however, we found that the actions from the legionella risk assessment were not always clearly recorded, such as the descaling of shower heads.

The environment was suitable to meet the needs of the people who lived there. The home was clean, tidy, well-lit and free from clutter.

The staff carried out regular checks on the environment including fire safety.

People's rooms were personalisedto people’s personal taste and interests. People were involved in cleaning their rooms and supported by staff as needed. We observed one person doing this during our site visit.

While the provider ensured the staffing levels met the commissioned support hours for the service, they did not make sure that staff, including agency staff, were qualified, skilled and experienced. They did not always make sure staff received effective support, supervision and development.

Some staff training had expired, this including mandatory and service specific training. This included training for supporting people when they became anxious, fire safety, first aid and food hygiene. There was no oversight of agency staff training and ensuring their compliance with the legal requirement of completing mandatory training on learning disabilities and autism. There were no records of staff’s qualification such as the Care Certificate. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. It is made up of the 15 minimum standards that should form part of a robust induction programme.

Staff supervisions were not always completed routinely or regularly. This placed people at risk of being supported by untrained and unsupervised staff.

Staff told us they felt they could approach the management team if they needed to and did not share any concerns in relation to training. While most staff were positive about the staffing levels in the home, one staff told us this was an issue which made completing tasks such as documentation difficult.

Improvements were needed to ensure staff were being recruited safely. This meant staff could be employed who were not safe to be supporting vulnerable people. There were gaps in recruitment checks. Records were not showing that the bared list Disclosure and Barring Service (DBS) certificate had been checked. The reason for leaving and conduct in previous care roles was not consistently verified and recorded for all roles involving children or vulnerable people.

People’s relatives did not share any concerns in relation to staffing levels and thought that staff had the training they needed to support their relatives.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some areas of infection prevention and control needed to be improved. There are no written procedures in place for dealing with high-risk laundry, not all Personal Protective Equipment (PPE) was available for staff who cleaned high risk areas and provide personal care to people. There was no procedure in place for the safe disposal of PPE.

Some of this had been implemented during the inspection however a procedure was to be developed and shared with staff for usage of these Infection Prevention Control (IPC) measures.

The service IPC risk assessment which had been recently updated contained information about staff receiving food hygiene training as a risk measure, however 5 staff were out of date with this training. The risk assessment did not include information of what PPE staff should use for personal care. The contact with bodily fluids section did not provide in-depth information in relation to control measures and risks related to cleaning of high-risk areas, did not detail how staff should deal with high-risk laundry and did not detail clear control measures in case of an outbreak. This placed service user and staff at risk of cross infection.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

People’s medicines profile lacked person-centred detail. Body charts were in place for the application of creams and ointments to people; however, they did not always contain information for staff in relation to the reason for administration and any signs of concerns to look out for. A list of people’s medicines was either not in place or had not been reviewed for a significant period of time. Where in place, information in relation to what medication was prescribed for was not available for staff to refer to. Lack of detailed guidance for staff could result in potential harm to people.

There was a process in place for routine checks of the competency of staff who administered medicines. However, oversight of this was not robustly maintained to ensure records reflected these were carried in line with the provider’s policy. This posed a potential risk to people for whom staff administer medicines to.

Some people were prescribed medicines to be administered on a when-required basis (PRN). However, there were no protocols in place to guide staff to make decisions about when these medicines would be required by people. This placed people at risk of being administered medicines incorrectly or not in line with their needs.

Stock control of medicines was not being maintained in line with the provider’s policy, for example for PRN medicine and homely remedies. A homely remedy is a medicine used to treat minor ailments. They are purchased over the counter and do not need to be prescribed. There were discrepancies in stock against records for prescribed medicines.

Where people had a list of approved homely remedies, this had either not been reviewed and agreed by the GP or had not been reviewed by the service in a long period of time. This placed people at risk of receiving medicines which were not suitable for their needs.

Medication Administration Records (MAR) were transcribed for all medicines, however these were not counter signed by a second staff member to ensure the accuracy of the recording, as per national recognised guidance. This increased the risk of medicine errors occurring.

People’s relatives did not share any concerns in relation to medicines.