South Park Residential Home

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

People were protected from the risk of harm and abuse, however we found some aspects of this needed attention including risk in relation to fire safety. This represented a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our last inspection, we found the provider had failed to always ensure peoples prescribed medicines were safely managed. This represented a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection during our assessment of this quality statement, we found enough improvement had been made to the way the provider managed medicines, which meant they were no longer in breach of regulation 12. Medicines systems were now well-organised, and people received their prescribed medicines as and when they should. At our last inspection, we found the provider's recruitment procedures were not robust. This represented a breach of regulation 19 (Fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection during our assessment of this quality statement, we found staff recruitment procedures had been improved and there were enough staff to support people. This meant they were no longer in breach of regulation 19. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to managers and staff. When concerns had been raised, managers reported these promptly to the relevant external agencies and collaborated closely with them to make sure timely action was taken to safeguard people from further risk. The environment was homely, however we have made a recommendation in relation to modernising areas and making the home more dementia friendly.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Managers supported staff to safeguard people from abuse. Staff understood how to recognise abuse and neglect, protect people from its different forms and to report any concerns to their line managers. Furthermore, the managers understood their legal responsibility to refer safeguarding incidents to all the relevant external agencies without delay, ensure they were fully investigated and to take appropriate action to minimise the risk of similar incidents reoccurring.

The provider's safeguarding policy and processes were in line with relevant legislation. The registered manager worked well with external agencies and acted in a timely way to make sure people were safeguarded and protected from further risk.

People told us they felt safe living at the care home and with the staff who supported them. One person said, "Yes, I feel perfectly safe living in this place.” Another person added, “It always feels so quiet and peaceful here. The staff are all lovely and they know how to look after me.”

Staff followed the guidance in people’s personalised risk management plans. This included guidance for staff to help them manage peoples prescribed medicine’s safely and to support people to safely evacuate the building in an emergency, known as a personal emergency evacuation plan [PEEP]. Risk assessments covered areas including risk to people, risk to others, risk to staff and risk to the environment. Each area given a risk score and then an overall risk rating which meant that staff had access to information about identified areas of high risk.

We observed staff supporting people in line with their risk asssessments. For example, those that needed mobility aids were provided the appropriate level of support. The premises were kept free of obstacles and hazards and we observed people moving safely and independently without any staff assistance around the care home.

People told us they were safe living in the home and did not raise any concerns about risks to their safety.

Staff were aware of the risks that people could be exposed to and knew what steps they would need to take to keep people safe.

People lived in a care home environment which was homely and people were comfortable in their surroundings. However, we noted that that a number of fire-resistant doors did not close flush into their frames when released, despite the provider conducting weekly internal checks on these doors. In addition, we found the care home’s physical environment, interior décor and soft furnishings were not always maintained to a good standard. For example, we found missing doors on an under the sink cupboard on one person bedroom, poorly lit communal areas, and worn and tired paintwork throughout the care home. We discussed these interior décor and furnishing issues with the owner at the time of our inspection who acknowledged the care homes interior was well overdue refurbishing. They confirmed an action plan was already in place for improvements to the homes interior to be completed within the next 6 months. Progress made by the provider to achieve this stated aim will be closely monitored by the CQC. The environment was not particularly ‘dementia friendly’ and most communal areas lacked any meaningful easy to understand pictorial signage, colour contrasting doors and walls or memory boxes near people’s bedroom doors for people living with dementia. A memory box is a container placed outside a person’s bedroom that holds special objects that are important to a person, such as photographs or ornaments. The introduction of the visual clues described above would benefit people living with dementia in the care home. We recommend the provider consider current guidance on making a care home environment ‘dementia friendly’ for people living there with dementia and take the appropriate action. It was positively noted that plans to convert the one remaining shared bedroom in the care home into a single occupancy bedroom were well underway with the work expected to be completed by Summer [2024].

Managers were told us that there were effective governance arrangements to monitor the safety and upkeep of the premises and equipment. However, despite one person being allowed to smoke in the homes conservatory/laundry area and another person partially managing their own medicines, no risk management plans were in place to help guide staff to mitigate the risks associated with both these activities. This meant staff might not have access to all the information and guidance they needed to reduce or appropriately manage these risks. We discussed both these risk management issues with the managers at the time of our inspection and they agreed to carry out the necessary risk assessments as soon as was practicable. Progress made by the provider to achieve this stated aim will be closely monitored by the CQC.

Regular checks were completed by managers and staff to maintain the safety of the care homes physical environment. This included regular health and safety checks on the homes electrical, gas and water systems. The provider had an up to date personal emergency evacuation plans [PEEPs] in place for everyone who lived at the care home. However, there was no fire safety risk assessment that had been completed by an external agency to provide reassurance around fire safety and the provider's current processes in place failed to identify the issue we found in relation to the fire doors not shutting fully into their door frames. No risk assessment/management plan/s had been carried out in relation to one person who was a smoking and had been given permission by the provider to smoke in the care homes conservatory/laundry area. The provider did not always appropriately maintain accurate and clear contemporaneous records of all the fire alarm tests and fire evacuation drills they assured us they routinely conducted in the care home. It remains unclear how often these fire safety tests and drills are actually carried out by the provider and which staff are involved.

Managers and staff feedback demonstrates people are receiving the standard of care described in this quality statement. Staff received regular and relevant training to support them in their roles and they were well supported by managers to learn and continuously improve their working practice. Staff told us about the training they had as part of their job roles and were knowledgeable about the topics they were trained in such as supporting older people living with dementia. Comments included, "We get regular training. I have just completed my Level 2 and started Level 3" and "Yes, the training is good. I started Dementia Level 3 least year." The registered manager told us they regularly reviewed staffing levels at the service to make sure there were always enough staff to meet people’s needs. A dependency tool was in place to review people's level of dependency and to ensure there was enough staff to meet people's needs. In addition, there were systems in place for the provider to identify and monitor staff training requirements and ensure it remained relevant and up to date. Staff told us they felt well supported by the management team. One staff said, "[The registered manger] is very supportive."

People using the service told us there were enough staff on duty to help and support them.

At our last inspection, we found the provider's recruitment procedures were not robust. This represented a breach of regulation 19 (Fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection during our assessment of this quality statement, we found staff recruitment procedures had been improved and there were enough staff to support people. This meant they were no longer in breach of regulation 19. The provider had developed a new application form which included details about previous work history. Staff files included evidence of reference, identity and right to work checks. Checks were also carried out on staff to make sure they were suitable to support people. This included checks with the Disclosure and Barring Service (DBS) who provide information including details about convictions and cautions held on the Police National Computer. Some aspects of staff recruitment procedures still needed improving. This included signing off interview assessment forms by a manager and also completing probation sign off checks. We discussed this with the registered manager who assured us this would be put in place. Staff received regular training in topics the provider considered mandatory such as Moving & Handling, Heath & Safety, Food Handling, Fire safety, Infection Control, Confidentiality, First Aid, Mental Capacity, Medication and Safeguarding.

There were enough suitably skilled and experienced staff to support people. We observed staff were visibly present throughout our inspection and deployed in sufficient numbers. The staff on duty matched the staff rotas for the day. People did not have to wait long for support from staff and staff were vigilant when people were moving around or undertaking activities. Staff regularly checked in on people who chose to spend time in their rooms or in quieter spaces around the service to make sure people were well and ask if they needed anything.

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

Staff were clear about their roles and responsibilities in relation to the safe management of medicines. Staff received medicines training and their competency to continue doing so safely was routinely assessed by their line managers.

Medicines systems were now well-organised and staff appropriately maintained medicines records. At our last inspection medicines records such as the controlled drugs register and peoples medicines profiles were not always appropriately kept by staff, up to date or accurately reflect the medicines people were prescribed. At this inspection we found no recording errors or omissions on any of the medicines records we looked. For example, two staff always countersigned the controlled drugs register when controlled medicines had been administered and peoples medicines profiles reflected the medicines they were prescribed. Staff received safe management of medicines training and their competency to continue doing so safely was routinely assessed by their line managers. Medicines were safely stored in lockable cabinets and trollies. People’s care plans included detailed guidance for staff about their prescribed medicines and how they needed and preferred them to be administered. This included protocols for people prescribed ‘as required’ medicines, which helped guide staff to manage these medicines safely.

People told us they received their medicines as they were prescribed. One person said, “I absolutely do get my medicines when I should. The staff are very good that way and never forget to give me my medicine’s on time.”