Green Park Care Home

We looked at all quality statements across the domains of safe, effective, caring, responsive and well-led.

The overall rating of this assessment was requires improvement. We found four breaches of the legal regulations in relation to safe care and treatment, management of medicines, IPC and good governance.

A new manager had commenced in post in June 2025 and had made positive changes to the service since their start date, however, there were some areas of improvement identified during the assessment. There were some inconsistencies identified within care records, and the management of medications required improvement. Risks were identified in relation to the environment, to include trailing wires within people’s bedrooms, broken toilet seats to ensuite bathrooms and damaged light fittings. Action was immediately taken by the manager to address the concerns identified.

The provider used an electronic care package system (PCS) for care planning and risk management. Whilst records were detailed and reviewed regularly, there were however, some inconsistencies within records which contradicted care being delivered. Plans were in place to review care plans, and the manager had introduced coaching sessions for staff.

Systems were in place to ensure people received their medicines as prescribed. However, we found some areas of improvement in particular for people refusing medications and the use of covert medications. Parts of the service were not clean and there were several environmental hazards identified placing people at risk of potential harm. The provider was responsive to the findings of the assessment and actions were taken without delay. We have asked the provider for an action plan in response to the concerns found.

Safer recruitment practices were in place. Staff received an induction with access to a range of training courses. Staffing levels varied across the units. This depended on the varying level of assessed needs of people. We have recommended a review of staffing levels within a unit of the service to ensure there were adequate staffing levels to meet the needs of people.

Observations evidenced staff were kind and caring, and feedback from relatives was positive. People had access activities and events throughout all units of the service. People’s bedrooms were person centred and there was access to communal spaces that accommodated different needs for example, a sensory room, workshop and garden room.

Staff provided positive feedback on leaders and the recent changes that had been made to the service. Visiting professionals confirmed there was good communication across the staff team and staff were responsive to people’s changing needs.

The manager submitted notifications in a timely manner and people were protected from abuse. Governance systems in place reviewed aspects of the service, however, some of the findings of this assessment had not been identified. We have recommended a review of the systems to ensure they cover all aspects of the service and highlight areas of improvement.