About the service: Park House is a purpose-built care home that consists of five units providing residential and nursing care for up to 111 people with varying needs including end of life and general assistance with everyday life for people living with dementia. At the time of inspection 92 people were living in the home.

People’s experience of using this service: People we spoke with told us that they felt safe living in the home however, during the course of the inspection we identified serious concerns with the service.

Complaints, accidents, incidents and safeguarding processes were inadequately managed and not reported by staff either through communication channels within the home or by using the provider’s electronic system. Audits of the service were ineffective and, in some cases, not carried out.

We identified that a lack of cohesive working and poor communication within the home had led to risks not being recognised and acted on.

Medicines were not managed safely and the monitoring information for people living in the home was not always completed fully. Risks were not always recognised by staff and acted on by the provider.

We saw recruitment and induction process into Park House for either permanent or agency staff was not robust. Staff had not attended training the provider required them to and there was no oversight of supervision, appraisal or induction by the provider. This placed people at risk of receiving inappropriate and unsafe care.

Parts of the internal and external environment posed a risk to people and infection control standards at the home required improvement.

People living at the home and their relatives indicated there were issues regarding staffing levels. We saw that there was a high use of agency staff and that this impacted on the quality of the care being delivered.

People told us that they felt staff respected them however, we observed behaviour that was not respectful and feedback from people living in the home was that there were few activities on offer. Confidentiality was significantly breached, this meant that the rights of people were not respected.

Rating at last inspection: The last inspection was carried out in September 2018 and was rated as Requires Improvement.

Why we inspected: This inspection was brought forward due to information of risk or concern in regard to staffing, moving and handling procedures and governance of the home.

Enforcement: The service met the characteristics of Inadequate in four key questions of safe, effective, responsive and well-led and Requires Improvement in caring. We are taking enforcement action and will report on this when it is completed.

Follow up: We will continue to monitor the service closely and discuss ongoing concerns with the local authority.

The overall rating for Park House is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within

This inspection took place on the 3 September 2018 and was unannounced.

Park House 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.

Park House accommodates up to 111 people in one adapted building across five separate units, each of which have separate adapted facilities. At the time of the inspection there were 93 people using the service many of whom were living with dementia and age-related health conditions.

This is the second time the service has been rated Requires Improvement.

At the last inspection in August 2017 we rated the service Requires Improvement overall. This was because the provider was in breach of Regulation 17 of Health and Social Care Act. There was no system to analyse complaints for themes and trends, the administration of medicines needed to improve and there were no systems to make sure that everyone had the opportunity to participate in customer satisfaction surveys. At this inspection we found that improvements had been made and the provider was meeting legal requirements.

The service has two registered managers one of whom was a registered nurse and was the clinical lead. 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.

Despite the improvements made we found the completion of some records, such as medication administration records and staff personnel records needed to improve. We also saw the mealtime experience and the opportunities for to participate in meaningful activities needed to improve to make sure they met the needs of everyone.

People and relatives told us they felt the service was safe. People were protected from the risk of abuse because staff understood how to identify and report it.

The provider had arrangements in place for the safe management of medicines. People were supported to get their medicine safely when they needed them. People were supported to maintain good health and had access to health care services.

Staff considered peoples capacity using the Mental Capacity Act 2005 (MCA). People's capacity to make decisions had been assessed. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The provider was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS).

People and their relatives felt staff were skilled to meet the needs of people and provide effective care. Staff were supported by management to undertake their roles and were given training updates, supervision and development opportunities.

People were encouraged to express their views and results of customer satisfaction surveys were positive. People and relatives felt listened to and any concerns or issues they raised had been addressed.

Staff supported people to participate in activities of their choice and trips to the local shops and tourist attractions had been organised.

People were supported to eat and drink sufficient amounts and they were given time to eat at their own pace. People's nutritional needs were met and people had a good choice of food and drink.

The service had a relaxed and homely feel. Everyone we spoke with commented positively on the caring and respectful attitude of the staff team which we observed throughout the inspection.

People's individual needs were assessed and care plans were developed to identify what care and support they required. Staff worked with other healthcare professionals to obtain specialist advice about people's care and t

This inspection took place on the 2 and 3 August 2017 and was unannounced.

Park House is registered to provide nursing and personal care for up to a maximum of 111 people. At the time of the inspection there were 83 people living there, most of whom were older people living with dementia or age related conditions and frailty. Some people were accommodated on short term respite basis. The service is provided in five 'units' over three floors which were accessed by way of a lift or stairs. Each of the units had a secure entry system to which people needed to use a key pad to gain entry.

Our last comprehensive inspection of this service took place on 17, 18 and 19 January 2017. The overall rating for the service at that time was ‘Inadequate’ During this inspection the service demonstrated to us that improvements have been made and is no longer rated as ‘Inadequate’ overall or in any of the key questions.

At the last inspection we found four breaches of the legal requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to medicines, risks to people’s health and safety, staffing levels, staff support, the need for consent to administer medicines covertly and the governance of the service. We asked the provider to take action to make improvements to the quality and safety of the service and the provider developed an action plan stating the steps they would take to meet the requirements of the law. During this inspection we found that improvements had been made but other improvements were required.

The service required 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. At the time of this inspection the service was being managed by two managers. One of them was a nurse and took the clinical lead the other took the lead for the day to day running of the service. Although the service also had two registered managers, neither of them still worked for the provider. Processes were in place for applications to be submitted to remove them from the register and for the new managers to apply to become registered.

At the last inspection the quality assurance and monitoring systems in place were ineffective. Although the provider’s systems had identified some shortfalls, action had not always been taken to rectify them. The provider had lacked oversight of the quality of the service provided and had therefor missed the opportunity to raise standards and drive improvement. At this inspection, we saw that improvements had been made. Regular audits of records had been undertaken and action taken to address shortfalls identified. However improvements were required to ensure action plans to address areas they had identified as needing improvement were always in place.

At the last inspection we found that medicines were not always being managed safely. At this inspection we found significant improvements had been made. However further improvements are needed in relation to guidance for administering as and when needed (PRN) medication.

At the previous inspection we found there had not always been sufficient numbers of staff on duty. At this inspection improvements had been made. People and their relatives told us and we saw, there were enough staff employed to meet people’s needs.

Improvements had been made in relation to care records. Daily records had been maintained and care plans had been reviewed as needed.

At our inspection in January 2017 we found staff had not always received regular supervision or annual appraisals. At this inspection we found this had been addressed.

At this inspection we found improvements had been made in relation to the quantity of food

This inspection was unannounced and took place on 17, 18 and 19 January 2017. At our last inspection 20 January and 4 February 2016 we found that the service had made significant improvements to the care and support of people. They had met the requirement actions and the warning notices set in 2015 and the home had been taken out of special measures.

Park House is a large modern building on three floors, located in a quiet residential area of Birkenhead. It is part of the Four Seasons group of health care services. The home is registered to provide accommodation and care for up to 111 people. The building is split into four units. The ground floor unit is for people who do not require nursing and also has a respite unit attached. The middle floor unit is for people with dementia who may require nursing and the top floor unit is for more frail elderly people who may require nursing. At the time of our inspection, there were 107 people living in the home.

There was a registered manager in post; Park House has two registered managers, one who is the home manager and the other who is the clinical 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.’

During this visit, we identified concerns with the safety and quality of the service. We found breaches in relation to Regulations 11, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

The staffing levels were seen to be adequate on the days of this inspection; however the staffing levels in December 2016 and up to 16 January 2017 were not sufficient to meet the care and treatment requirements of the 107 people living there.

Senior staff told us they did feel supported by the registered managers however there were staff who told us they did not feel supported. Supervision meetings were taking place but not for all staff. Annual appraisals had not been provided to ensure staff were happy, competent and that their role at the home was meeting their aims and also the aims and philosophy of the organisation.

We found that medicines were not being managed consistently in the four units. There were issues with medicine room temperatures and medication fridges, PRN stocks and recording. There were inconsistencies on all units for the recording and the storage for a once controlled medicine. On one unit a controlled drug that was not being used was being stored. A person was receiving their medication covertly by staff and the provider had not followed the correct procedure as they were crushing tablets and adding to juice for administration. Records confirmed that people were receiving the medication prescribed by their doctor.

We requested the personal emergency evacuation plans (PEEPs) for the 107 people currently living at the home that contained personal information about their needs in an emergency situation. We were not provided with a PEEP’s and were told in a meeting with senior management they were not available.

People told us they felt safe with staff. The clinical manager who was the safeguarding lead had a good understanding of safeguarding. They had responded appropriately to allegations of abuse and had ensured reporting to the local authority and the CQC as required. However the CQC was concerned about the notifications sent through in relation to unwitnessed falls and the severity of the injuries sustained by two people.

People had a choice in the meals that they received and were ordered the day before however we were told that the units at times did not receive sufficient quantities of food and this caused issues. This was discuss