Park View

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to good governance.

This service scored 57 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider did not take timely action in response to risks and concerns or prioritise safe good quality care.

We did not identify a consistent culture of learning and improvement. Actions identified from the audits which were carried out were not completed without delay and some action had been in progress for 2 years, being re-identified without further escalation.

While processes were identified by the provider for review of people’s care, these had not been robustly and consistently followed.

Staff were sharing concerns through various channels in relation to areas such as people not always being supported correctly, culture in the service, inconsistencies in staff approach and restrictive practices. We were verbally assured by the management team in relation to these concerns; however, we did not see recorded evidence of how these concerns had been addressed.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

As detailed under the previous quality statement of this report, we identified areas for improvement in respect of the provider’s shared direction and culture.

At the time of the assessment there was no registered manager in place. The service was overseen by one of the senior support workers who stepped up to be the acting manager. They were supported by a senior support worker and a representative of the provider.

The acting manager was not present during the assessment due to circumstances beyond their control; therefore, we were unable to gain feedback from them. The senior support worker told us they felt fully supported by the acting manager and the provider representative and that this structure was working well.

The provider shared with us their plans in relation to the new leadership structure of the service as well as the timeframe for its implementation. Leaders were open about issues identified within the serviceand they were responsive to feedback received following our assessment.

Staff told us the management team was visible and approachable. An agency staff member told us the manager was; “very friendly, makes an effort to talk to staff, encourages people and residents.”

People’s relatives were complimentary about the management of the service; however, some concerns were shared in relation to the inconsistencies in the management structure.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had policies and process in place to support staff in raising concerns. They also provided staff with information about how concerns can be escalated.

Information related to safeguarding was displayed in an easy read format in the home for people living in the service to access.

Staff, including agency staff, told us they felt listened to when raising concerns to the management team. An agency staff member told us; “Residents are always welcomed by management, and [they] make sure that they [people] are ok.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

People were being supported by a diverse staff team. Staff told us they felt supported and did not share any concerns about they way they were treated. This included agency staff who were working on a regular basis in the service.

Policies and procedures were in place to support staff in their role. We did not see records of Equality and Diversity training being provided to staff in the service, however staff confirmed this was being provided.

Examples were provided of support offered to staff to carry out their roles, such as occupational health referrals.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had not made improvements and did not have an effective system in place to monitor the quality and safety of care and drive improvements. The provider’s audits and checks identified areas of improvement. However, actions to address these, despite being on their action plan for a significant period of time, continued to not be effectively addressed nor appropriate action taken without delay where progress was not achieved as expected. Some of these actions include the shortfalls we identified during the assessment, particularly related to risk assessments, mental capacity assessments and care documentation as well as training and staff supervision.

Audits carried out were not effective in identifying some of the concerns we found during the assessment, for example related to infection prevention control, restrictive practices and safe recruitment.

Audits of people’s medicines were not being carried out in line with the provider policy. The last monthly audit was carried out in January 2025 and did not identify the shortfalls we did during the assessment.

All these failures places people at risk of receiving unsafe and unsuitable care and support.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

In the main, health and social care professionals provided positive feedback about how they worked with the service.

There was some evidence of joint working with professionals and accessing health support for people when required. Referrals were being made, for example to medical professionals, however outcomes were not always clearly updated in people’s care documentation.

People were accessing the local town and amenities as well as other towns in the nearby geographical areas and one person was attending a local day centre. However, we did not see evidence in people’s up to date support guidelines of whether people were supported to build community links and if opportunities were created to get involved in meaningful ways.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had failed to meet their legal requirements and demonstrate a commitment to drive the improvements in people’s care through their governance and quality assurance systems.

There was little in place to enable improvement to the quality and safety of care to take place and there was little strategy to address the shortfalls the provider has been consistently identifying for a long period of time, in some cases for over 2 years.

The provider and management team were receptive of our feedback which they took on board and started considering actions to take to make the improvements.