Grove Park

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

During our assessment of this key question, we found concerns around the assessments of people’s needs and the skills and knowledge of staff which resulted in shortfalls in the quality of people’s care and treatment. The provider had failed to ensure staff understood their responsibilities within the Mental Capacity Act 2005 when working with service users’ who may lack the capacity to make some decisions. This resulted in a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Shortfalls and concerns about service user’s care had not always been identified and when this had occurred there was insufficient action taken to ensure service users received effective support to meet their needs. There was a lack of effective clinical oversight and governance to ensure service users received care and treatment that met their assessed needs which resulted in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s needs were not always assessed with them or in line with current guidance which increased the risks of people not receiving effective care and support. One example, one person told us how they were not involved with their needs assessment or plan, “I don’t think I have one, I haven't been asked to contribute to any plans I know of.” Records relating to this person confirmed they had capacity to make decisions independently. Grove Park supports a number of people who may not be able to tell staff about their needs and choices and therefore the information gathered in initial assessments and care plans was essential to ensure staff had enough information to provide effective support. Some people were living with dementia and may experience behaviours that challenge. Assessments lacked detail and failed to provide staff with guidance to support people when they experienced distress. One person described how they had been impacted when a person experiencing confusion entered their room, “I have had men come to the room, one was in my bed. Another man was at my door just standing there staring in” They went on to tell us how they now chose to not leave their room. The provider satisfied us that measures are now in place to mitigate the risks of this happening again.

Staff relied on other staff to share information about people’s needs they described people’s health needs, however, there were shortfalls in their knowledge of the persons preferences and communication. This increased potential risks of harm to people and staff. One staff member spoke about an incident when a person was aggressive towards them and what they could have learnt from it,” I could have left [person] for a minute and come back.” Care plans lacked guidance for staff or details of strategies to support communication and learning.

Care plans did not always contain details about the person’s preferences, occupation, hobbies or interests. This meant essential information was not always available to staff and resulted in people not always receiving support in an holistic manner in line with the person’s choices. For example, one person told us how they wanted to be supported to maintain their independence as much as possible. Records relating to support did not include details of plans or working towards outcomes with people.

People living with dementia were not always supported in line with current evidence-based practice. Records relating to care did not always consider peoples interests, strengths or abilities. For example, records relating to care described a person walking in the corridor. Staff had not always considered the reasons why a person might be walking with purpose. Staff had noted this person might be disorientated at times however, there was limited information or guidance on how to support this person when they experienced this.

Staff and leaders told us the service is not meeting people's needs. Following our assessment visit the provider told us they were reviewing people’s needs and taking action where they find the service is not equipped or skilled to meet peoples needs.

Care management processes in operation did not always contain information in relation to current evidence- based good practice. Care plans were focused on health needs and had not always considered the persons preferences to maintain independence or control. For example, one person told us they wanted to maintain control of their medicines, this had not been risk assessed by staff.

People provided generally positive feedback. One person spoke of support from a health professional helping to maintain mobility, “If it's nice and dry [they] take us around the block. Another said,” Its not too bad at all. [The registered Manager] came to my home and knew I needed rehab but it hasn’t materialised.”

Staff provided feedback on changes implemented following our assessment visit. For example, one told us,” The day staff have had some changes, we have to answer the bells within 5-6 minutes.” Another said,” It’s not until someone comes in and suggests another way, its improving.” The provider has taken immediate action to review staff practice to ensure staff are supported to meet clinical expectations.

Partners who spoke with us told us about challenges they experienced working with Grove Park. For example, “Communication is an area that could be improved. It is often difficult to get through to the team on the phone and there are often no responses from e-mails, this has been previously identified in the developmental meetings.” Another told us,” It would be good if they worked more closely with [health professionals] to develop their care planning / knowledge - although we had a plan to meet regularly with the leads - sadly this meeting did not happen and we were not notified this meeting needed to be cancelled before attending. This has been a common experience for myself / other professionals and family I have worked with since Grove Park opened.”

Staff skills with care management systems have not always supported information sharing. For example, Registered manager had reported challenges with sharing care records with the local authority and with CQC as part of our assessment. They told us,” I am pleased you have come in as it highlights the need for the new system. “Following our assessment the provider told us of their plans to replace the care management system and also how they were now able to access information effectively.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

People were not always supported to achieve positive outcomes. For a number of people, staff were using bed rails without effective assessment considering whether their use was safe, appropriate or the least restrictive measure. Staff had failed to review or monitor the risk associated with this practice. Subsequent to our assessment the provider’s investigations had identified some people experienced avoidable harm.

Staff provided feedback on changes implemented following our assessment visit. For example, one told us,” The day staff have had some changes, we have to answer the bells within 5-6 minutes.” Another said,” It’s not until someone comes in and suggests another way, its improving.” The provider has taken immediate action to review staff practice to ensure staff are supported to meet clinical expectations.

Processes in operation did not always direct staff to consider how to support people to maintain independence and control. For example medication care plans included reference to a person’s “dependency level, identified need and care action”, however this had not considered their potential involvement or how to support them to maintain control.

People were not always supported by staff who respected or understood people’s rights around consent. Records relating to people contained contradictory information about capacity and consent which potentially increased risk of harm from unnecessary restrictions. Staff had not completed Mental Capacity Assessments (MCAs) which would have assessed whether the person had capacity to make and understand decisions and records referred to Best Interest decisions staff had completed without fully including people or those important to them. People told us staff generally respected their choices and asked their permission. One person told us, “Yes, they ask and I tell them. I have my particular ways.” And “I tell the staff how I like things done, they do listen, they are good.”

Staff we spoke with were unable to provide assurance they understood the principles of the Mental Capacity Act and this resulted in them recording decisions without due consideration of the persons capacity. Following our assessment we sought assurance from the provider who told us they would, “Review all MCAs and address concerns with staff understanding and awareness.”

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). However, people were subject to blanket measures through the use of bed rails which had had not been fully considered within the MCA. This meant consideration had not always been given to least restrictive options. The provider’s processes and working practices did not ensure an adequate level of scrutiny and oversight that was needed to ensure people were protected from the risk of harm, abuse and improper treatment.