The inspection took place on 29 and 30 January 2019 and was unannounced.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve to at least good.

When we completed our previous inspection on 21, 22 and 30 November 2017 we found concerns relating to risk assessments not always in place resulting in a breach of Regulation 12 Safe Care and Treatment and also concerns regarding governance resulting in a breach of Regulation 17 Good Governance of the Health and Social Care Act Regulations 2008 (Regulated Activities) 2014.

We found on this inspection the provider was no longer in breach of Regulation 12 Safe Care and Treatment or Regulation 17 Good Governance. We did however, make recommendations within this report related to audits and oversight of all medicines management systems, staff deployment and also systems of confirming consent had been obtained from people.

Green Park Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is comprised of five units for people with dementia, nursing and residential care needs. They have a maximum of 105 beds and there were 93 people living at the home at the time of this inspection. A new unit had been opened since our last inspection for people with dementia care needs.

There was a registered manager present in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

A CCTV/Care Protect camera system had been installed since our last inspection. We found the provider had not recorded they had obtained consent or agreement from people prior to switching cameras on to film them in communal areas of the home.

We made a recommendation about systems of consent not being robust enough.

Medicines had not always been managed effectively as we found high levels of stock which had not been identified through the medicines audits we viewed.

We made a recommendation regarding medicine stock audits not being robust enough.

We received mixed feedback from people in relation to staffing levels to meet people’s care needs.

We made a recommendation the provider reviews their systems of staff deployment within the home.

The audits being undertaken which we viewed had not identified the issues highlighted on this inspection related to recording consent, issues were found regards high prescribed medicines stock and staff deployment.

We therefore, found the provider remained in breach of Regulation 17 Good Governance.

We found there were systems in place to assess and record risks for people. Electronic care plans we viewed included a range of risk assessments.

Some people ‘s fluctuation in their weight had been recorded and people were being referred to healthcare professionals.

The environment was appropriate for people living with dementia and there were activities within the home.

We found the home was clean and infection control standards were being met.

Most people were complimentary about the food and systems were in place to monitor people’s food and fluid intake.

Safeguarding systems were in place and staff understood their responsibilities to report abuse.

Complaints had been dealt with appropriately and meetings with relatives/service users were taking place in the home.

Staff were receiving supervisions and appraisals. Staff were also receiving training with competency checks seen.

You can read about what actions we asked the provider to take at the back of this report.

This unannounced inspection of Green Park Care Home took place on 21, 22 and 30 November 2017.

When we completed our previous inspection on 22 and 23 May 2017 we found concerns relating to safe care and treatment, consent and governance. At this time these topic areas were included under the key question of safe, responsive and well-led. We reviewed and refined our assessment framework and published the new assessment framework in October 2017. Under the new framework these topic areas are included under the key question of safe, effective and well-led. Therefore, for this inspection, we have inspected this key question and also the previous key question of responsive to make sure all areas are inspected to validate the ratings.

The care home was previously inspected on 22 and 23 May 2017 and was rated inadequate and placed in “special measures.” At that time we found four breaches of regulation in relation to safe care and treatment, consent, dignity and respect and governance. We issued two warning notices for safe care and treatment and governance and requirement actions for the regulations related to dignity and respect and consent.

We asked the provider to complete an action plan to show the Commission what they would do and by when to improve and ensure they were meeting the legal requirements. This inspection took place to check if the provider had made enough improvements to meet their legal requirements.

Green Park is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home comprised of five units for 105 people. At the time of our inspection one unit was closed to admissions. The provider confirmed they intended to open the fifth unit in early 2018. 59 people were living at Green Park Care Home at the time of this inspection.

There was no registered manager. A home manager was present for the inspection and they confirmed their intention to apply to become the registered manager at the care home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

On this inspection we found the provider had made improvements related to the concerns raised within the warning notices for safe care and treatment and governance.

These improvements meant the provider had demonstrated they had implemented a robust action plan to address the concerns we raised on the last inspection and within the warning notices.

However, we identified new concerns related to safe care and treatment and governance on this inspection. There remained breaches of the regulations related to safe care and treatment and governance.

During the inspection, we became aware of a serious incident around choking. This incident is subject to further investigation and we examined the risks of choking on this inspection.

We found people were not always being kept safe from harm. Risk assessments such as for those at risk of choking were not in place. Safe recruitment practices were not always in place. This meant that the provider had not done all that was considered reasonable to mitigate risks to people supported by the staff.

There were improvements seen in the provider’s quality assurance systems however they were not robust enough to highlight all of the concerns found on this inspection.

Medicines were being managed safely within the care home including prescribed medicines which were to be administered as and when (PRN). This was an improvement since the last inspection.

People were supported to have maximum choice and control of their lives and staff supported th

This inspection was carried out on 22 and 23 May 2017 and was unannounced on the first day.

Green Park Care Home compromises of five purpose built units and is located in the suburb of Great Sankey in the Warrington area. The service can accommodate up to 105 people who require twenty four hour care. The service provides residential, nursing and dementia care. At the time of our inspection there were 81 people living at the service.

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service had a manager in place who had commenced the application process to become the registered manager with Care Quality Commission.

The service changed registered provider in September 2016 and has not been previously inspected under Care Quality Commissions new methodology. During our inspection we found a number of breaches of the Health and Social care Act 2008. CQC are now considering the appropriate regulatory response to the concerns we found. We will publish the actions we have taken at a later date.

Medication was not administered to people safely. There was a lack of instructions and guidance available to staff on the use of ‘as required’ (PRN) medication. For example, what the medication was for, when it should be given and interval between doses. Staff failed to follow the instructions provided by a GP when administering PRN medication to one person putting the person’s health and safety at risk.

The quality assurance systems in place were not effective, they failed to identify that checks which were required across the service had not been carried out. They also failed to identify that action plans had not been completed to address improvements which were needed. There was a lack of management oversight to ensure checks were carried out as required across the different areas of the service. Records were not properly maintained to make sure they were accurate and fully complete. Care plans and supplementary care records lacked important information about people’s needs and they failed to record the care people had received. There were many examples were records including care plans and audits had not been fully completed, signed and dated.

Accidents and incidents were recorded by staff, however there was a lack of evidence within audits to demonstrate that a robust analysis of falls, patterns or trends were identified. There were no recorded actions completed for two people who had multiple falls within a period of one month, to state what had done to prevent and minimise the risk of further harm/occurrences.

The Mental Capacity act (MCA) was not always followed to ensure people rights and best interests. Records in relation to MCA (2005) were completed in full and there was evidence of decision specific assessments and associated best interest meetings in place for people who were assessed as lacking capacity to make decision about their care, treatment and support. However, the records contained standard and set phrases for each question. These phrases and responses were the same for all people living at the service. Information regarding people’s ability to consent was not always accurate or in line with information recorded in care plans. Staff were observed seeking peoples consent in practice.

People were not always protected from the risk of malnutrition and dehydration. There was a lack of action taken when it was identified that people had lost significant amount of weight over a short period of time. Weight losses recorded for eight people across the service showed they had lost between 3kg – 7kg in weight, despite this no action was taken in response. There was no evidence that