Parkgate Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment, the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice. Quality assurances processes were either not in place or where they were, had not been effective at identifying the issues found during this assessment. For example, concerns around infection prevention and control and medicines management , had not been identified by the provider’s quality assurance processes. This meant the provider had not always demonstrated continuous learning and improvement for the service. However, the provider had been open to feedback and taken immediate actions to make service improvements. Relatives told us they knew how to raise concerns. Staff listened to concerns about safety and investigated and reported safety events. Management were aware of the duty of candour and their legal responsibilities to be open and transparent when things went wrong.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People accessed healthcare appointments when required. Hospital passports were in place to support people when they needed to go to hospital or attend clinic appointments. Staff described how they shared information about a person’s communication and health needs with hospital staff. This ensured people had effective support during their hospital stay. A relative said, “[Person] had various visits to the hospital as their care needs had changed quite a lot.” They went on to say that not all hospital staff had read the notes but “the home was on it like a ton of bricks and fed back the information to me.” Feedback from professionals about working with Parkgate Manor was positive. One professional said, “There was never an appointment time that the service were unhappy to attend; they have always been flexible. [Person] had a long-standing clinical need that required regular attention, and [staff member] was great at providing me with regular updates meaning we could review them back in clinic, as necessary. [Staff member] was never afraid to reach out which is invaluable to [person] improving and recovering.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The provider shared concerns quickly and appropriately. We observed staff support people safely. Relatives told us people were safe. Comments included, “I feel [they are] safe at the home,” and “[Person] appears to be happy, and I have no cause for concern.” Staff received training in safeguarding and understood their responsibilities to report concerns. Comments included, “We have refresher training which keeps it in the front of your brain,” and “If there are concerns, we know the pathways to report. If a safeguarding happens, we get feedback.” Management reported and investigated safety concerns appropriately.

Safeguarding and whistleblowing policies were in place and were regularly reviewed and updated.Some people were subject to deprivations of liberty (DoLS) for their own safety. DoLS applications had been submitted to the appropriate authorising bodies where required. There were systems to monitor this to ensure people were only deprived of their liberty to receive care and treatment when it was in their best interests and legally authorised under the mental capacity act. Where there were conditions stated in people’s DoLS, there were records to show they were met.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. We observed staff supporting people safely to minimise risks. For example, during one mealtime a person was observed to be putting too much food into their mouth at once. Staff gently encouraged the person to slow down to avoid a risk of choking. Where people were at risk of choking or aspiration, staff sought advice from specialist services to ensure risks were mitigated. We observed meals prepared as per people’s guidelines and where needed, staff supported people to eat and drink. Where people were at risk of malnutrition, they were weighed regularly. Where there had been unplanned weight losses, staff sought advice from the GP and guidance for fortifying meals was put in place. A relative said, “[Person] is having more seizures, but the home let us know every time [person] has a seizure and when they are in hospital. Staff seem very good and someone stays there with [them].”

There was guidance for staff for specific health conditions such as epilepsy, catheter care and for when people were anxious. Some people’s positive behaviour support plans (PBS) transferred with them when they moved from other services. Some information needed to be reviewed now they had settled into the service to make sure it was still relevant. Staff were knowledgeable about people’s specific health and wellbeing conditions. Comments included, “We get regular training on risks and as a team we support each other. A staff member told us a person could get distressed but that, “[Person] is easily distracted. We offer a cuppa, and it always works.” Each person had a detailed, personalised emergency evacuation plan with clear guidance for staff and emergency services on the support they would need to evacuate the building safely in the event of a fire.

The provider did not always detect and control potential risks in the care environment. For example, they did not have systems to monitor window restrictors. All other areas in relation to equipment, facilities and technology supported the delivery of safe care.

Out of 6 windows checked we found 1 with no restrictor. This was addressed immediately by the maintenance team. The service’s system for checking window restrictors had lapsed. The manager confirmed following our site visit that all windows had been checked and monitoring of windows had been reinstated.

There was a system to ensure the service equipment was maintained and serviced. There were regular servicing contracts which included electrical safety and fire risk assessment. Checks took place to ensure a safe environment was maintained. These included fire safety and water temperature checks. Staff received fire safety training and fire drills were undertaken to ensure staff knew what actions to take in an emergency. Staff told us that if they identified any maintenance or safety concerns with the service they recorded this in the maintenance book and issues were addressed promptly. We saw evidence of this during our inspection.

Records showed that staff received inconsistent access to supervision. The majority of staff had only received one form of supervision in 2025. The provider’s policy stated that all staff would receive some form of supervision 6 times a year. The provider did not have appropriate systems to explore gaps in employment history for new staff. All other aspects of recruitment were carried out safely.

People had shared staffing hours and four people received additional one to one hours to meet their specific needs. Rotas showed that there were 8 staff on duty. In addition to this, the management team (the manager, care coordinator and training and quality administrator) were available to support as needed. The manager told us there were two staff vacancies and that regular bank and agency staff covered these hours. Staff told us there was an on-call service out of hours for advice and support. The manager said they provided additional staff if required based on the needs of people, daily activities, or if people had appointments.

Staff received a detailed induction to the service. A staff member who had moved to a senior role told us they received, “A proper induction to the role.” A support worker told us they worked through their induction booklet in the afternoons and evenings. They said, “I’m not frightened to ask if I don’t understand. I’ve had catch ups with [training coordinator] and if I have any problems I can go to a senior or the manager.

Staff attended a mixture of mandatory training and additional training that was essential for staff to complete to work at Parkgate Manor. Training was provided two weekly, by an external training agency to ensure all staff were up to date. One person was due to be prescribed new emergency medicine and there was a programme in place to make sure there were enough staff trained to provide this support. When a person required specialist support for example in relation to enteral feeding (feeding through the stomach), epilepsy, catheter care, and stoma care, staff had received appropriate training.

During our visit, the manager adapted the application form to ensure gaps in employment were captured and they also adapted their interview format to make sure staff were asked to provide an update on any gaps. Following our site visits the manager told us all staff had attended an additional supervision meeting. They also confirmed the task of ongoing supervision had been delegated and was now shared by all the management team.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We found some aspects of infection prevention and control needed improvement. The service policy was to place soiled linen in a specialist water-soluble bag; this is then placed in the washing machine and would dissolve during the washing process. This helps to reduce the risk of cross-contamination to staff and other people. However, staff told us that they opened these bags and emptied the washing into the machine. Although personal protective equipment (PPE) was available, this was not always being worn within the laundry when linen was being handled. We raised these issues with the manager who took action to address them immediately. The laundry room did not have flooring that could be appropriately cleaned. The manager told us this was due to water leakage and plans were in place to address this. However, we were told the work needed to be carried out when the laundry was not in use, which meant it would have to be done at night. Following our assessment the manager confirmed that this was on the action plan to be completed in the next month.

There were 3 housekeeping staff employed. Two staff worked mornings during the week and 1 at weekends. Tasks were scheduled daily, weekly and monthly and records kept of all cleaning completed. The service was clean and tidy throughout. Housekeeping staff were aware of their responsibilities in relation to the prevention of the spread of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. We found areas of medicine management that need to be improved in relation to record keeping. When medicines had been given ‘as required’ staff recorded this, but they did not routinely record if the medicine had been effective in line with good practice guidance. There was a medicine policy for staff to follow when they needed to add medicines to the medicine administration record (MAR), for example, adding verbal instructions from a GP. This included ensuring the handwritten entry was signed by the staff member completing the entry and checked for accuracy and signed by a second appropriately trained member of staff before it was first used. However, we found examples where handwritten entries had not been signed by any staff member when added to the MAR.

Some people were prescribed more than one PRN for either pain relief or anxiety. Although staff knew people well protocols did not always give clear information about when each should be given and the steps to take before using them. We raised these issues with the manager, and they told us this would be addressed. Following the assessment, the manager sent us copies of updated protocols that had been introduced.

Other aspects of medicines were managed safely. Medicines were ordered, administered, and disposed of correctly. Only staff who had received medicine training and been assessed as competent gave people their medicines. Staff competency was checked to ensure staff continued to follow the correct procedures. Medicine administration records were completed when medicines had been given. There were pictorial pain charts available which staff told us they could use to support people to communicate if they were in pain and ensure appropriate actions were taken. Staff who gave medicines were knowledgeable about people and the medicines they had been prescribed. They ensured people received medicines in a way that suited each individual and supported them to take them safely.