Park Lane House

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

Systems and process were not effective in identifying improvements required to improve the care experience of people. Accidents and incidents were not always recorded and there was a lack of evidence showing where lessons were learnt. Staff felt supported and confident in speaking up and raising any concerns they may have had.

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.

Staff we spoke with shared the values and vision of the organisation. Staff and management understood the importance of listening to the views of people and their relatives regarding the service. Staff understood how to support people with their diverse needs. The registered manager was transparent with us during this assessment and took our feedback in a positive manner.

The provider led on team meetings and supported the team with moving forward and progressing the service to impact people’s care in a positive way. The registered manager gathered regular feedback from stakeholders and people who used the service. Staff we observed shared caring and respectful values. Care plans and risk assessments included people’s individual diverse needs.

Staff told us the management team were approachable and always available. Staff told us they felt supported and they could speak with the registered manager and provider with openness. Staff were aware of the on-call system. The registered manager told us they had an open-door policy and ensured they were present. The registered manager and provider were transparent with us and informed us of complaints received regarding management and the oversight of the home. The provider evidenced actions they had taken to respond to the concerns raised.

We saw evidence the registered manager had regular supervisions with staff. Team meetings took place and we saw this provided a ‘safe’ space for staff to openly speak of concerns. Team meetings shared the complaints and concerns the home had received, and staff provided their thoughts. Staff worked with the provider and registered manager towards improving and resolving the issues.

There was a whistle blowing policy in place. Staff could access the policy if needed. Staff were also provided with the employee handbook when starting with the provider. The provider had procedures in place for staff to follow when needing to speak up.

Staff felt they were treated fairly. The provider considered their diverse personalities. Staff felt the registered manager adapted to people individually to ensure they could do their best in their roles and provide good care. Staff were offered flexible working patterns and told us, where appropriate, the provider would accommodate working patterns. Staff told us they were included and could provide feedback and were listened to by the registered manager.

The provider had policies and procedures around equality, diversity and inclusion. We found guidance and information was also available in the employee’s handbook.

The registered manager did not have effective systems in place to monitor aspects of the records kept within the home. For example, the registered manager had no tracker to keep an oversight of people who required deprivation of liberty safeguard (DoLs) authorisations. Staff and leaders had a delegation chart in place that allowed them to identify their responsibilities. Staff also told us they were aware of their job descriptions and expectations.

The provider’s governance systems were not effective and resulted in a lack of monitoring to manage risk. This had the potential to cause an impact to the safety and quality of people’s care. Audits completed did not thoroughly check areas such as medicines, infection control and health and safety. Recruitment audits were not found to be in place, which meant the concerns we found during this assessment were not identified by the provider or registered manager. Best interest meetings were not present for people and the registered manager told us they had not implemented these. However, it was on their improvement plan to embed into the service. This meant decisions were being made for people who lacked mental capacity without the proper legal authority to do so. Personal emergency evacuation plans (PEEPs) did not capture people’s up to date mobility needs. For example, 1 person who could independently evacuate had recorded in their PEEPs they needed a wheelchair. We checked with staff and the registered manager. Both confirmed this information was incorrect. Care plans were not easy to follow, for example, reviews took place meaning the front page of the guidelines created in the care plan were not up to date. The system in place meant staff had to go to the back of the support plan guidance to identify the most up to date information. This increased the risk of staff not reading the most up to date care plan guidance. The failure to implement effective systems and processes to ensure oversight of the service was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 17(1) Good governance.

Staff and the registered manager told us they had a good working relationship with stakeholders involved in the service. The registered manager had good relationships with other stakeholders and worked to ensure people had access to the services they need.

Feedback from partners was positive. The local authority quality team told us how the service interacted with them and welcomed any feedback. The quality team completed an action plan which identified areas needing improvement. We did raise a concern that some actions were dated back to 2021. For example, it was identified care plans needed improving and an electronic care planning system was going to be implemented. At the time of this assessment site visit, this was not in place.

Processes were not effectively in place to ensure external partners were notified of relevant information. For example, the registered manager did not complete Care Quality Commission (CQC) notifications for all reportable incidents. This raised concerns around the level of understanding the registered manager had regarding reportable incidents. This meant incidents had the potential to not be recorded appropriately.

The registered manager and provider had service improvement plans in place. We saw where feedback was received, this was taken in a positive way and the registered manager was responsive to implementing new ways of working to improve the care provided to people.

Accidents and incidents were not always recorded on a formal record. This meant detail was not present to evidence the investigation and lessons learnt following any incidents. We did not see evidence of the registered manager recording lessons learnt or evidence where changes had been implemented and the reason for the change in care.