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 inadequate. 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.
 

This service scored 56 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There had been some improvements since the last inspection to the systems the provider had to record accidents and incidents. These were now recorded directly onto the provider’s electronic system by staff and individually reviewed by the service manager.

Despite this improvement, records did not always indicate they had been routinely analysed for all possible trends, for example, in relation to behaviour incidents. For one person, incidents took place in December 2025 and January and February 2026. However, they had not been analysed by the provider until April 2026. For this person, their care documentation and the incident analysis carried out by the provider's behaviour team, provided conflicting information to what the behaviour might indicate. This meant staff may not have had clear or consistent information about the person’s behaviour, leading to potential inconsistent support.

Lessons learnt was a standard agenda in staff meetings. For example, all staff were booked onto a local face-to-face session to share learning from an incident in another service managed by the provider.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Hospital passports were completed and in date together with health action plans. The service fully supported any hospital admissions and investigations. Consistent records of medical appointments were maintained.

People were supported with health appointments, for example, to visit the dentist, optician and chiropodists. There were referrals liaising with community learning disability services and mental health services. Records also indicated health surveillance with the GP and primary health care nurses.

A person’s relative told us, “[Person has] been through medication change (which were) done very well, we have online meetings with the psychiatrist, manager and keyworker every six months.” Another relative said, “[Name has] had eye test, teeth looked at and visits to doctor.”

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.

The service maintained a record of safeguarding concerns reported by staff. However, information captured in relation to actions taken was not robust. Recommended actions were recorded, but it was not clear what action had actually been taken, the outcome of the recorded concerns nor the rationale for not being reported externally. The service manager did not have oversight of the safeguarding log as this was being managed centrally by the provider. 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.

Following our site visit feedback, the provider told us they decided that by the end of May 2026, safeguarding concerns would be moved onto their electronic system and the managers at service level would have oversight of these.

Staff employed by the service received safeguarding training and they felt able and confident to raise concerns with the management team if needed. Safeguarding was a standard agenda at staff meeting and different scenarios had been explored with staff at a recent meeting.

Restrictive practice audits had been since our last inspection and the provider had assessed all the restrictions people had in place.

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

People’s relatives told us their loves ones felt safe living at the service. A relative said; “Yes definitely, now and again I ask him if he feels safe and happy.”
 

Some improvements were needed so that the provider worked well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There had been improvements in relation to risk management and the oversight the provider had in this process. All risks on the electronic system were reviewed in line with monthly care plan reviews.

The majority of risks had been identified, assessed and mitigated, although some of those referenced in our previous inspection had not yet been fully implemented and were available for staff on the provider’s electronic system. For example, in relation to the use of equipment and finances. These were implemented by the management team during our inspection.

Positive behavioural support (PBS) plans had been reviewed. However, staff reported that the newer versions were not as effective as the previous, describing them as overly wordy and lacking sufficient direction. There were no clear guidelines for staff about the prioritisation of risk, or how to de-escalate or manage unwanted reactions to behaviours.

Personal emergency evacuation plans (PEEP) had been reviewed and the evacuation plan for the service was updated accordingly. Some of the generic risk assessments for the service were slightly overdue for review. This was rectified during our inspection and an overview created to prompt managers of approaching deadlines in the future.

Staff were aware of people’s risks and how to support them. Feedback from people’s relatives suggested staff know people well and they were pleased with the care provided. One relative told us, “Always excellent care, been fortunate. [Person has] got a very good key team and core team works around him.”
 

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There had been improvements in relation to infection prevention and control since our previous inspection. Personal protective equipment (PPE) was available for staff who cleaned high risk areas and provide personal care to people. An infection prevention and control (IPC) audit had been carried out since the last inspection. However, this did not identify that the risk assessment had not been updated with the areas of improvement previously identified. This was rectified during this inspection.

Information related to prevention of infection was available for staff around the home, including hand washing posters. The home was generally clean and free of odours. The floor in the annex flat and communal dining and kitchen areas was replaced during our inspection as part of the provider's refurbishment plans. There were also imminent plans to replace the flooring in the communal bathroom.

A relative told us, “I’ve never known the house not to be clean and well maintained.”
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

There had been improvements since our previous inspection and people’s medicines were now managed safely.

People’s medicines records showed they received their medicines safely in the way prescribed for them.

There were suitable arrangements for ordering, storage and disposal.

If medicines were prescribed to be taken ‘when required’ there were person-centred protocols or care plans in place to guide staff when these might be needed. Records were in place to show that risks were considered for people using higher-risk medicines such as flammable topical preparations.

Staff had regular training and competency checks to make sure they gave medicines safely. New medicines audits and checks took place which identified improvements that were needed, and actions were recorded.