Grove Park

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

The overall rating for this key question is requires improvement. During our assessment of this key question, we found concerns affecting the health safety and welfare of people, including Infection Prevention Control (IPC) processes and assessing risks to people’s health and welfare. People were not always protected from the risk of harm and abuse. Staff did not always fully understand their responsibilities under safeguarding with respect to identifying potential abuse, escalation and the reporting of concerns. Oversight and governance processes to ensure people received care and treatment in a timely manner were not always effectively monitored. For example the monitoring of call bell response times and as a result this increased the potential risk of people not receiving the support they needed. These concerns resulted in continued breaches of regulation. There had been some improvements since the previous assessment, medicines were now stored and managed safely, people received their medicines in line with the prescriber’s guidance. Managers and staff had opportunities to analyse incidents, whilst this was in the process of being embedded, it was apparent lessons learnt had started to mitigate and minimise potential risk of recurrence. You can find more details of our concerns in the quality statement findings below.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders had not always promoted an open proactive culture to safety events, incidents were not always identified, reported or investigated. There were shortfalls in processes which impacted on learning lessons and embedding good practice. Some people’s records contained information relating to potential harm from incidents with other people living at Grove Park which had not been fully investigated. This meant opportunities to improve practice to reduce harm had not always been identified or investigated. Following our feedback, the manager told us they were working on improvements in relation to these areas. A staff member told us, “Things have improved in some ways, we are more organised”. People and their families told us they were not always confident their safety concerns were listened to or acted upon. However, some spoke of how things had improved, one relative told us, “We are better communicated to now when we make complaints either individually or as a group of people, things are changing.”

People and their relatives said there had been a general improvement in the standard of care at the service. A visiting professional told us, “I think the standard of care at Grove Park has greatly improved in the past few months, which I think is due to clear leadership from the new manager and the employment of more trained nurses”. However, some relatives expressed concern with shortfalls in staff communication about changes to people’s health conditions and updates involving external health professionals. The manager spoke of communication challenges the service had and to address this had arranged for the nurse on duty to be responsible to manage incoming telephone calls to improve the flow of communication and the continuity of care people received. People’s needs were assessed prior to moving into the service. A senior staff member joined the manager and completed assessment at people’s homes or if required, at hospital. People were involved in their assessments and specified likes and dislikes, where people required support from health or social care professionals, this was noted in the assessment. The provider had implemented an online care management system which meant current and relevant basic information was now accessible.

People generally told us they felt safe within the service and should they not, they would speak with staff or management. One person told us, “I do feel very safe, they are lovely people. I would talk to the manager if I was worried”. Whilst people we spoke with expressed that they were generally happy with their care, our assessment found elements of care which did not meet the expected standards and there was a continued breach of regulation. People were not always kept safe from avoidable harm because the provider’s systems to safeguard people from the risk of harm or abuse was not always followed. Through the assessment process, we identified a number of allegations of abuse from feedback we received and the providers records. We referred our concerns to the local authority, and they were being considered through safeguarding processes. For example, there were several records relating to events where people with complex needs had expressed emotions physically and verbally which resulted in potential harm to other people. Staff and managers had not always considered these events within incident management or safeguarding processes. The provider had not always ensured statutory notifications had been submitted to CQC in accordance with their regulatory responsibility. Whilst managers and staff had received safeguarding training, they had not demonstrated an understanding of their responsibility or of potential types of abuse. Following our feedback the manager spoke of their improvement plans and had arranged for senior staff to complete enhanced safeguarding training and ensured the notifications were submitted in retrospect and shared plans of how future notifications would be monitored to ensure they were submitted in a timely way. There were areas of improvement which included the removal of blanket restrictive practices. The use of bedrails had now been risk assessed. We observed people’s safety and best interests were now being followed.

Risks associated with people’s health and support needs were not always understood or managed safely. Whilst the provider had taken action to address the management of skin integrity risks identified at the last assessment, the provider had not fully considered risks in a person centred manner. This resulted in a continued breach of regulation in relation to person centred care. Care plans were not always worded in a dignified manner and lacked information about people’s dementia and how this might impact on their behaviour. Staff lacked guidance on understanding potential triggers and how to support people when they were expressing distress. Care plans lacked guidance for staff when supporting some people with poor appetite who had significant unexplained weight loss. A relative expressed their concern with the level of staff knowledge, “The finer details get missed, staff know the basics but don’t always appreciate the individual things. For example, I am here a lot. [loved one] is very shaky and can't pick up a cup and have a drink without help, some of the staff just don’t understand that and leave a coffee in front of them and just walk away.” The lack of understanding and monitoring of risks increased the risk of potential harm to people. Following our feedback the manager told us how they were working on improvements to the service, in particular working with dementia specialists to improve staff understanding. We observed staff supporting people in communal parts of the service with meals in accordance with their dietary needs.

People and relatives provided mixed feedback about the environment; they told us about the spaces they could and couldn’t use within the service. Some people with specific needs told us they were unable to use showering or bathing facilities. Senior staff confirmed some facilities were not available to everyone and they were ensuring admission assessments now included ability to access facilities to ensure the service could safely meet the needs of people. Several people told us they were in the process of waiting to move to alternative services, the provider was working with people and their plans. Processes were in place to ensure the safety of the premises and equipment; however, they were not always effectively considering people being able to access facilities. For example, a relative spoke of concerns accessing a bathroom when the hairdresser visited as this was, “Always full of equipment”. We saw communal spaces were generally homely; however, the provider had not always considered the needs of people living with dementia. For example, there were no pictorial references to help people recognise their space. The manager told us they were aware of areas which looked clinical and shared plans of working with external professionals to make the service more homely and suitable for people living with dementia. We observed people appeared relaxed and comfortable and had their own private rooms which they were encouraged to personalise. We observed people’s rooms were decorated with personal items and photos of their loved ones. The service was spacious and light with adequate space for people to mobilise safely with their mobility aids. Technology was used to enhance people's care. Call bells were in use for people to call for staff assistance. For those unable to use call bells, sensor mats were used in people's rooms so when they moved staff were alerted and could go to offer their assistance.

People generally spoke positively about the staff; however, some people told us they felt there was not always enough staff on duty. Their comments included, “If I ring the bell they come quickly”. A relative told us, “There are not enough staff they are always rushed”. Another relative told us they had complained about the length of time staff took to respond to calls for support, “We can ring the bell for ages and can't get anyone”. Following our feedback the manager told us how they monitored call bell records, “We are also discussing call bell response on a daily basis during handovers and 10:10 management meetings.” These monitoring processes did not always provide assurance people received support in a timely manner. Records of call bell responses corroborated shortfalls in people receiving support in a timely manner. Some had taken in the region of 25 minutes for the call bell to be answered. At our last assessment there was a breach of regulation in relation to staff deployment. The provider had taken some action to improve call bell monitoring processes, they were unable to provide assurance this was operating effectively to ensure improvements were embedded and minimise the risk of recurrence. We received mixed feedback from staff about staffing levels. One staff commented, “Staff are allocated a wing but there’s no other clear plan.” Another told us, “We were using a lot of agency staff, now we have all our own staff, we rarely use agency now”. We observed there were enough staff to support people during the day of our assessment. Staff consistently told us about increased training opportunities available to support them in their roles, this included working with external professionals to improve staff skills to support people with dementia. Staff were recruited safely, pre-employment checks had been carried prior to their employment, this included references, background checks and the right to work in the UK.

Infection prevention and control (IPC) risks were not always safely managed. This was a breach of safety regulations. At the start of the assessment, we were not made aware of a suspected outbreak of infection impacting two people in the service. A number of staff were observed not taking necessary precautions such as changing gloves after entering each person’s bedroom. Several staff told us they were not aware of any current infection. One told us, “I was at handover this morning and nothing was said about barrier nursing for anyone.” A senior staff member told us there was a warning symbol on the electronic system that would indicate an infection was present and this was how the staff member would know there was an infection outbreak. Staff did not ensure unwashed crockery and cutlery was dealt with promptly to prevent any cross infection. We saw a number of people walking around the service, including one person who was in the kitchen looking through contents of a box they had found. Shortfalls with IPC processes, communication and monitoring of infection risks increased the potential of infections not being managed safely and spreading within the service. Following our feedback the manager informed us they would ensure all staff were reminded about Personal Protective Equipment (PPE) use and arranged for the nurses to pass on information to all staff in the handovers.

At our last assessment there was a breach of regulation as medicines were not being managed safely. The provider had taken action to address shortfalls and at this assessment there were significant improvements, and the provider was no longer in breach of regulation. People were now receiving their medicines safely and as prescribed. There were policies and processes in place to ensure people received medicines safely; these were supported by an online medicines administration record. ‘When required’ PRN medicine protocols (documents which can support the safe and effective use of PRN medicines) were in place for prescribed medicines. However, those in place lacked some detail to support staff to understand how and when to use the medicines safely. For example, records didn’t always contain how a person expressed pain, or signs and symptoms staff needed to monitor. A staff member told us, “Staff know people well so would recognise signs of pain, this should be included in the protocol.” Following our feedback senior staff took action to address this. Records confirmed a reduction in PRN medicines used to manage people’s behaviour. This provided assurance people’s needs were being monitored and reviewed regularly. People spoke positively about their experiences, one person told us, “Yes, they come and give me my medicine. They tell me what it’s for.” However, relatives shared some concerns about medicines not always being readily available or kept safely. They told us how managers had taken action to investigate and address their concerns. Medicines were now being stored in line with the manufacturer’s recommendations. Staff now carried out regular stock checks for medicines and records of audits were available. The provider had taken action to ensure medicines processes were monitored by a visiting health professional. One told us, “I find the unit is very responsive to any interventions I make and acts upon them in a timely manner”.