South Park Residential Home

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

At our last inspection, we identified concerns about how the provider operated their established governance systems, which was not always effective. This was because they had failed to pick up and/or address a number of issues we identified during that inspection relating to the safe management of medicines, staff recruitment, notifying the CQC about significant incidents and DoLS and record keeping. This placed people at risk of harm and represented a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection during our assessment of this quality statement, we found some improvements regarding how the provider operated their oversight and scrutiny systems had been made, but not enough. We found no evidence that people had been harmed however, yet further improvements were still required to show us the provider now operated their governance systems effectively. This meant they remained in breach of regulation 17.

This service scored 50 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The providers governance framework did not ensure they continuously learnt and improved, and that risks were always understood and well-managed. The provider had developed an improvement plan and followed the actions it set out to take to address most of the issues we identified at their last inspection. This included improving how medicines, staff recruitment, incident reporting and service user involvement were managed and monitored. The quality and safety of the service people received was routinely monitored by managers who conducted regular audits and spot checks on staffs working practices, and gathered feedback from people living in the care home, their relatives and staff. However, these newly improved governance systems had failed to pick up and/or take appropriate action to address a number of current issues we identified at this inspection. This included how the provider managed fire safety and staff kept records. For example, despite weekly checks on the services fire-resistant doors, we found most of these doors did not automatically close into their frames when released, contrary to the providers own audit findings and recognised best fire safety practice. Furthermore, the provider had failed to always appropriately maintain accurate and clear contemporaneous records of regular fire alarm tests and fire evacuation drills they conducted, contrary to the providers own fire safety procedures and recognised best fire safety practise.

The managers acknowledged they needed to continue improving how they operated their oversight and scrutiny systems. An external social care professional representing a local authority also added, “The local authority is requesting the service follow fire safety guidance and advice from London Fire Brigade for care homes and improve how they monitor and scrutinise their fire safety arrangements at South Park Residential Home.”

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.