Park 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

We identified 1 breach of the legal regulations in this key question. This related to good governance. Staff described a poor culture at the service where there was no shared direction. There was evidence the management team were aware of this, but had failed to address the issue. Staff meetings were not effective and staff did not feel the provider was supportive enough. The provider and registered manager did not always notifiy the CQC of notifiable events. There were no effective audits in place to ensure care delivery was safe and effective. Staff received little support through regular supervisions and poor communication hindered effective teamwork. There was a lack of oversight at the service and systems to monitor the quality and safety of care were ineffective. Staff had not received sufficient training to allow them to support people effectively and staff feedback on how to improve the service had not been sought.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff described a poor culture at the service and feeling that they were not all working in a shared culture or direction within the organisation. One staff member told us, “Staff morale is very low. You can tell by the body language everyone is low. No communication between people up top and its like a guessing game sometimes with management.” The registered manager, deputy manager and operational manager told us that one of their biggest challenges was changing the culture of the service.

There was evidence of a negative culture within the home. The management were aware of the concerns however had failed to address them. There was lack of effective induction for agency workers, agency workers relied on permanent staff to inform them of people needs and requirements. There was little evidence of meaningful team meetings to allow information to be shared amongst staff and for joint decisions to be made in implement change.

Staff did not feel the provider was offering the support or guidance they needed to do the job to the best standards. One staff member said, “I very rarely go to the manager as just get nothing from them.” The registered manager, deputy manager and operational manager told us they were working daily to instil trust and be available for staff when they needed any support.

The provider and registered manager had not ensured CQC were always notified about certain incidents as legally required. We reviewed the provider’s safeguarding records and found 4 safeguarding referrals which had been made to the local authority. However, CQC had not been notified about these. The registered manager confirmed this was an area of learning about what was notifiable and confirmed they would ensure all appropriate notification were submitted in future. There were no effective audits in place to ensure the home operated safely. The atmosphere lacked nurturing and support, with little evidence of supervision or appraisals to help staff feel valued and motivated. Poor communication hindered teamwork, and there was no indication that staff were encouraged to participate in decision-making regarding the operation of the service.

We received mixed feedback regarding freedom to speak up. Some staff told us that they felt management were approachable. However, other staff said they didn't feel there was any point speaking up as nothing would change or they would be listened to. The registered manager, deputy manager and operational manager told us they have an open-door policy, so staff could raise any concerns. We were not assured this system was effective.

There was lack of regular supervision for staff. This meant staff were not always given the opportunity to reflect on their practice, identify any learning needs and to receive feedback on their role. A whistleblowing policy was in place, but there was no evidence that it was being utilised or that staff were encouraged to speak up. There was no evidence of any staff surveys. People were not actively involved in sharing feedback to allow for improvements. People had raised concerns however people were not always happy with the response from the provider.

Staff told us the management team, or the provider had not taken any action to monitor, review or improve the culture at the service.

There was a recruitment policy in place however this was not always followed. Communication between staff and the management team was poor due to lack of effective ways to share information including team meetings, supervisions and handovers. The training records evidenced some staff had received training in relation to equality, diversity and inclusion.

Feedback from staff and leaders across the service at all levels did not provide assurance or evidence of robust, effective or well-embedded governance and oversight measures. This meant the management team and the leaders failed to ensure there was an oversight of the service to ensure risks and concerns were identified and action taken.

Governance systems in place were not effective, when audits were being completed identified actions were not followed up on. Accident and incidents were not always analysed to ensure themes and trends could be identified to mitigate risks. Staff did not receive regular supervision to enable them to reflect on their practice, identify any learning need and to raise concerns. There was evidence of group supervision however these were following on from concerns being raised. There was evidence of director visits however there was little evidence to suggest improvements were being made.

People did not have access to the local community however people told us they could see the GP when they wanted.

Leaders told us about were the service needed to improve and the work they were undertaking, and this included collaborating with all relevant external stakeholders and agencies. However, there were systemic failings in the leadership, governance and safety of the service.

Partners told us they had difficulties instilling good, effective partnership working with the service. Partners had on occasions raised concerns regarding the care and treatment of people at the service. When partners had offered guidance, training and support to the provider, this was not always accepted.

The provider had support from the GP who visited weekly. Safeguarding referrals were not always submitted when required. We identified incidents that required reporting to the Local Authority in line with the Care Act 2014 however these referrals had not been submitted. During the assessment the registered manager raised these. The provider was not aware of their responsibilities to share safeguarding concerns with CQC.

Staff told us the management team did not always listen to them and were wanting changes with the new provider. One staff member said, “Not much has changed apart from staff leaving and some things like handover and agency. I hope they improve." The registered manager, deputy manager and operational manager told us they wanted staff to make suggestions so they could improve the quality of care people were receiving. The management team told us they were moving onto an electronic care planning and recording system in the future.

There were no effective systems in place to ensure all staff had the necessary training to enable them to support people safely. Whilst the registered manager and provider had identified ways to make improvements happen within the service these had not been implemented effectively. There was no evidence staff were included in ways to drive the service forward and implement positive changes.