Parkgate Manor

Parkgate Manor is a residential care home providing personal care to 24 people at the time of the

inspection. The service can support up to 40 people. The service is a large manor house, set in private grounds within a small rural village. Some people have specialist needs associated with downs syndrome, autism or dementia. A number of people have age related health conditions such as diabetes or mobility issues.

People's experience of using this service and what we found

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

The model of care and setting did not always maximise people's choice, control and independence.

People were not always supported to have maximum choice and control of their lives, but staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There were systems to ensure people's needs were assessed but people and their relatives, where appropriate, had not been involved in the process. Significant progress had been made to increase opportunities for people to participate in activities, but further work was required to make activities more person centred. The design and layout of the premises was centred on communal living and did not support the promotion of people’s independence.

Risks to people were assessed, monitored and managed safely. People’s medicines were managed safely. The systems in place ensured that people were protected from abuse and improper treatment. Parkgate Manor was kept clean. There were enough staff to safely meet people's needs. Emphasis had been placed on ensuring that staff had the skills, knowledge and experience to meet people’s needs.

Right Care

Care was not always person-centred or promoted people's dignity, privacy and human rights.

Some staff practices although well intentioned were institutional and did not enable people to make informed choices. For example, people were served tea with milk already included. There were not enough opportunities to enable people to share their views about how they were supported.

Recording did not always demonstrate that people’s assessed needs were being met. It was recognised however, that the electronic care planning system was still in its infancy and with further training for all staff this could eliminate some of the shortfalls found.

Staff were caring in their approach and people responded warmly to them. People had increased access to activities, external entertainers were visiting the service and there were opportunities for people to go out more.

Right culture

The ethos, values, attitudes and behaviours of leaders and care staff did not always ensure all people using the service could lead confident, inclusive and empowered lives.

Systems to obtain people’s views were not effective either through keyworker meetings or surveys and further work was needed to adopt a more person-centred approach to enable people’s individual views to be sought. There were no recent surveys to seek the views of people’s relatives. Staff morale had improved and whilst staff had opportunities to share their views at meetings, further development was needed to ensure there were increased opportunities for staff to attend supervision meetings.

The systems for auditing of care plans and health checks were not effective, and this left the risk of issues not being identified quickly and support sought. Auditing in relation to infection control, health and safety and medicines were clear and thorough and any shortfalls found had been addressed promptly.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Inadequate (published 14 March 2022).

This service has been in Special Measures since 14 March 2022. At this inspection we found the provider remained in breach of regulations. However, during our inspection the provider demonstrated that some improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The overall rating for the service has changed from Inadequate to Requires Improvement.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We have identified continued breaches in relation to person centred care and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

About the service

Parkgate Manor is a residential care home providing personal care to 28 people at the time of the inspection. The service can support up to 40 people. The service was a large manor house, set in private grounds within a small rural village. People had their own bedrooms and there were shared bathrooms, eating and living areas.

People’s experience of using this service and what we found

Right Support

The model of care and setting did not maximise people’s choice, control and independence.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Risks to people were not always assessed, monitored and managed safely. Systems in place did not always protect people from abuse and improper treatment. The provider had not always acted to manage infection risks. People’s medicine support was not being managed safely. There were not always enough staff to safely meet people’s needs. The design and layout of the premises did not support or promote people’s independence.

People’s needs were not always holistically assessed to consider what people wanted and needed and people did not always achieve good outcomes that effectively met their health, social and emotional needs. Staff did not always have the necessary skills, knowledge or experience to know how to meet people’s needs.

Right Care

Care was not always person-centred or promote people’s dignity, privacy and human rights.

Staff did not always communicate or support people in dignified or respectful ways. Staff did not always offer people choices or involve them when supporting them with activities, medicines and meals. We saw staff often moved people in wheelchairs without asking their permission.

People’s strengths, levels of independence and quality of life was not always accounted for when planning and reviewing their care, and people were not involved in this process. Staff did not always communicate in accessible ways with people. Recommendations and actions identified by partnership agencies regarding people’s support needs had not always been implemented or consistently followed to ensure people achieved good outcomes.

Right culture

The ethos, values, attitudes and behaviours of leaders and care staff did not ensure all people using the service could lead confident, inclusive and empowered lives.

People were not being supported to regularly identify, or review, on-going individual aspirations and life goals. People did not have support to follow their interests and take part in appropriate social activities.

Staff and health and social care professionals told us the values and attitudes of staff and management did not empower people and there was a long standing unchanged culture of “doing things the way they had always been done” which was causing a lack of empowering person-centred support to continue.

Internal systems of staff and management appraisals and supervisions were not operating to help staff to understand and fulfil their responsibilities and support staff to be positively accountable for their performance. Staff morale was very low, and we were told there was not an open or transparent culture within the service. People and staff were not encouraged to contribute to developing the service.

There were minimal internal quality assurance systems and processes to audit or review service performance and the safety and quality of care. Where checks and audits were carried out, they had not always identified or prevented issues occurring or continuing at the service. Where issues had been identified, the registered manager and provider had not always effectively overseen or ensured actions were taken to maintain or improve the quality and safety of the support being delivered at the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Why we inspected

We undertook this inspection to assess that the service is applying the principles of Right support right care right culture. The inspection was prompted in part due to concerns received about staffing and people not being kept safe from abuse. A decision was made for us to inspect and examine those risks.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risks, abuse, dignity and respect, person-centred care, consent, staffing, notifying CQC and displaying CQC ratings at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will act in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Parkgate Manor provides accommodation and personal care for up to 40 people who have learning disabilities. Some people had specialist needs associated with downs syndrome, mobility or special diets. Some people communicated verbally, and others used gestures and body language to make their needs known. The majority of people were under 65 years of age. There were 31 people living at the service when we visited. Accommodation was on ground and first floors.

There had been two changes to management since our last inspection. Quality and governance systems had not been fully kept up to date. A new manager was appointed in February 2021. They were aware that there were areas particularly in relation to record keeping that needed improvement. Systems were being established to ensure care plans were updated, to ensure greater analysis was carried out in relation to welfare checks, records held in relation to daily records, and activities. There was limited oversight of some people’s mealtime experience to ensure support was always person centred. Some incidents of potential abuse had not been reported to the Commission as is required.

The service was clean and tidy throughout. Enhanced cleaning had been instigated as a result of the pandemic, staff had received additional training and the service had a visiting procedure that complied with government guidance. The measures taken ensured people were protected, as far as possible, from the risk of COVID-19.

People were protected from the risks of harm, abuse or discrimination because staff knew how to recognise and respond to any possible abuse. There were enough staff working and available to provide safe support for people. Recruitment practice was thorough and ensured only suitable staff worked at the service. There were suitable arrangements to respond to any risk to people and to provide people with their prescribed medicines.

The new manager had established a positive culture at the service and was working closely with staff to ensure people were supported appropriately and safely. They understood their responsibilities and were making positive changes in the service to improve systems and outcomes for people. There was a clear management structure and staff knew their individual roles and responsibilities.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture and work was continuing to ensure care was always provided in a person centred way.

Right support:

• The model of care and the layout of the setting had been developed to ensure people had a choice in where to spend their time. There was a large dining room and a separate sun lounge and two other lounge areas. In addition, there were very large grounds/gardens and some people chose to spend time outside daily. There was an ongoing programme of redecoration and improvements had been made to the toilet areas. Guidance in care plans was being updated to ensure they included more detailed advice on how to meet people’s individual needs and wishes.

Right care:

• The service tried to ensure people received support from staff who knew them well as individuals. Where agency staff were used, they were staff who had worked at the service regularly and knew people well. Improvements were being made to ensure that care was more person-centred but further work was required to fully achieve this.

Right culture:

• Some people attended day centres throughout the week. Staff supported others to take part in activities of their choice to meet their individual needs and wishes. This included meals out, walks on the seafront, arts and crafts at Parkgate and gardening projects. Those that were able, were encouraged to participate in activities of daily living such as folding their own laundry, clearing the table or emptying bins. The home was actively recruiting for a new activity coordinator so there were not as many activities provided as there would normally have been. People were supported to maintain contact with their families and friends.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement. (published 12 July 2019). There were no breaches at that time. Since then an infection prevent and control (IPC) assurance inspection was carried out on 4 March 2021 and the provider was found to be in breach of regulation. The provider completed an action plan after the inspection to show what they would do and by when to improve. At this inspection we found improvements had been made to IPC and the provider was no longer in breach of that regulation. However, the service remains requires improvement and we found breaches of regulations 17 and 18. This is the second time the service has been rated requires improvement.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, caring, responsive and well led.

The ratings from the previous comprehensive inspection for the key question not looked at on this occasion was used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Parkgate Manor on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The home had been closed to visitors due to a recent Covid -19 outbreak. The home had three sets of cubicle toilets that had not been risk assessed to minimise the risk of cross contamination or infection. We found personal possessions had been left in bathrooms following personal care, increasing the possibility of shared use. There were limited records to demonstrate that baths and shower areas were cleaned after use and non-slip mats bathmats were left on the floor. No infection control audit had been carried out throughout the lockdown.

Policies and procedures were being reviewed at the time of our visit. We signposted the provider to resources to develop this area.

During the outbreak, the pandemic had put pressure on staff levels. Although the registered manager managed the situation, they did not follow government guidance.

The home had remained closed to all visitors due to a recent Covid-19 outbreak. However, visiting was about to start again in line with government guidance on 8 March 2021. The day centre had been designated as a visiting area as this had a direct outside entrance that supported safe visiting arrangements. Staff had supported people to maintain contact with their loved ones with the use of video calls and telephones.

There was a programme to ensure people and staff were tested regularly. This was alongside daily temperature testing for everyone and observing people for any signs or symptoms of Covid-19.

There were daily, weekly and monthly cleaning routines and all were recorded. Alongside normal cleaning routines all touch points were cleaned four times a day. All staff wore scrubs and personal protective equipment (PPE) such as aprons, gloves and masks. Staff had received training on infection control, the putting on and taking off of PPE and hand washing. There were clear arrangements in place for the management of laundry and waste.

When the home had their outbreak, people were cared for in their bedrooms and commodes were bought for individual use in rooms. As people recovered, tables in the dining rooms were spaced out to ensure social distancing. Some were moved to the sun lounge and to another lounge area.

A staff questionnaire had been completed to assess how staff were coping throughout the lockdown. Advice and support was provided for any staff who were assessed as vulnerable.

We asked one person how they were coping with lockdown and they said, “It’s ok, it doesn’t bother me.” They also told us that they liked to talk to their relative on the phone. Where possible people kept to their usual routines, there are large grounds and over the past year a large poly tunnel had been erected and people who chose to, were encouraged to take part in growing vegetables. A number of people liked to spend time in the garden. We were told others liked to go for a drive or a walk on the sea front or to a park.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 12 July 2019). There were no breaches of regulation. At this inspection, we only looked at IPC arrangements. We found the provider to be in breach of regulation 12, Safe Care and Treatment. This was because the provider had not fully implemented national guidance in response to the Covid-19 pandemic.

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Parkgate Manor on our website at www.cqc.org.uk.

The service has not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. A service of this size would not be commissioned today. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them

People’s experience of using this service:

People were supported by staff who were kind and considerate, however people were not always supported to develop their independence or learn new skills. Goals had recently been developed for a small number of people but due to them being new progress could not be seen. After the inspection the provider sent us records relating to goals for people. However, the majority of these were dated from 2018 and there was no evidence of any progress made.

People’s care plans were inconsistent in the level of detail to guide staff. Care plans for people who could challenge required more information to ensure people received consistent care. After the inspection the provider sent us an action plan recording information about how to support people. However, as it was not recorded in the care plan there was a risk that new or agency staff may be unaware.

Some people had communication tools in place to help them express themselves. However, most people did not have tools and limited work had been done with them to develop them.

Some support were based on staff time rather than people’s needs. For example, a drinks trolley came around twice a day and there was no opportunity for people to access drinks in between these times apart from with meals. After the inspection the provider told us people could access drinks at the kitchen and tuck shop, however inspectors did not observe anyone accessing these on the day of inspection.

Some people went long periods of time without any meaningful staff interaction.

People were supported to move safely, and screens were used to give them privacy.

People’s health needs were managed well, and staff worked closely with health professionals to meet people’s health needs.

People told us they liked staff and enjoyed the food at the service.

The registered manager undertook regular audits and had worked with a consultant to put together a development plan.

Staff told us they felt well supported and that the management team were approachable.

There were enough staff to meet people’s needs and they had the training required to meet people’s basic needs.

Rating at last inspection: Good, report published 30 September 2016.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Whilst a number of people had good communication skills, others needed support with communication and were not able to tell us their experiences, so we observed that they were happy and relaxed with staff.

There was a registered manager in post. 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.

We carried out an unannounced inspection on 18 and 24 March 2015 where we rated the home as ‘Requires Improvement’ in all areas. We issued specific requirement notices in relation to dignity and respect, the need to supply notifications where appropriate and quality assurance systems. We received an action plan from the provider that told us how they would make improvements. We carried out this comprehensive unannounced inspection 13 and 14 July 2016 to check the provider had made improvements and to confirm that legal requirements had been met. We found that overall significant improvements had been made in the running of the home.

There were some areas where more clear record keeping could have demonstrated the work carried out in a person centred way. For example, documentation that related to complaints, service user surveys and keyworker meetings. However, following the inspection the manager sent us copies of new formats that would be introduced that, completed well, would address this area.

There were enough staff who had been appropriately recruited, to meet the needs of people. Staff had a good understanding of the risks associated with supporting people. They knew what actions to take to mitigate these risks and provide a safe environment for people to live. Staff understood what they needed to do to protect people from the risk of abuse. Appropriate checks had taken place before staff were employed to ensure they were able to work safely with people at the home.

The manager and staff had received training on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. They had assessed that restrictions were required to keep people safe. This related to the need to have electric gates preventing access onto a very busy road where visibility was limited. Appropriate referrals had been made to the local authority for authorisation.

Staff had a good understanding of people as individuals, their needs and interests. Some people attended day centres, activities were provided within the home daily, external entertainment was provided and people were supported individually to have their needs met. People’s spiritual needs were met.

People had access to healthcare professionals when they needed specific support. This included GP’s, dentists and opticians. Where specialist healthcare was required, for example, from a physiotherapist or speech and language therapist, arrangements were made for this to happen.

People were asked for their permission before staff assisted them with care or support. Staff had the skills and knowledge necessary to provide people with safe and effective care. Regular training was provided which was specific to meeting people’s needs. If staff identified additional training they would like to receive, arrangements were made for this to happen. Staff received regular supervision and support from management which made them feel valued. Staff spoke positively about the way the service was managed and the open style of management.

This was a responsive inspection following concerning information received by the CQC about the safety of people who used the service. Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We judged there was an insufficient number of qualified, skilled and experienced staff to meet peoples' assessed needs. The service did not use a dependency tool for calculating staffing levels and we observed that some people were potentially at risk due to staff being unable to observe them. There were a number of unwitnessed falls and incidents between people who used the service. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

We found that incidents which should have been reported to CQC and the local authority had not been referred as safeguarding alerts. The lack of safeguarding referrals meant that the service had not taken appropriate action to protect people who used the service. A compliance action has been set in relation to this and the provider must tell us how they plan to improve. Staff had received training in safeguarding and there were appropriate policies and procedures in place. The staff we spoke with however were unsure of their roles and responsibilities in this area.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that there was at least one person who used the service who required an application to be submitted under DoLS. This had not been done. Some people's movements had been restricted by the practice of locking their room doors when they were not in use. It was unclear why some people had not been offered a key to their rooms. Although care staff were trained in the Mental Capacity Act they had not been trained in the use of DoLS and they demonstrated a lack of understanding and awareness about these safeguards.

We found that staff treated people with dignity and respect. We observed positive interaction between staff and people. One person told us, 'I like living here.'

We looked at four care plans and found they were comprehensive. They reflected the care that we saw delivered.

We found the building was suitable for people and there were systems in place to ensure the building was maintained.

We looked at four staff files and found there were effective recruitment and selection procedures in place.

We found the home had effective systems to assess and monitor the quality of service that people received.

We observed staff interacting positively with people. Care plans were bulky but contained very detailed advice and guidance for staff. Where appropriate, specialist advice and support was obtained to meet people's needs.

There were sufficient numbers of staff on duty and staff felt well supported. Staff were clear about what they should do if they suspected abuse. They were also clear about the home's complaint procedure. Some infection control issues were identified during the inspection. There was no effective system in place to ensure that this area was monitored regularly.