Archived: Parkfield Rest Home

Updated 8 November 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection was carried out by one inspector. We visited the service on 17 August 2016. The inspection was unannounced.

We spoke with both people who lived at the home. We spoke with the provider and senior care worker on the day of the inspection and contacted the part time care worker by phone on the Sunday following our inspection.

We examined the care plans of both people and checked the recruitment and training files of both the staff employed. In addition, we checked records relating to the servicing of equipment and premises checks.

We emailed a local authority safeguarding officer and a two commissioning officers. We also contacted the local Healthwatch organisation. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. two commissioning officers responded to our requests for information. Following our inspection we spoke with a community psychiatric nurse, a GP, a reviewing officer from the local authority and an independent advocate.

We checked our information system and noted that the provider had not sent us any notifications since they registered with the Care Quality Commission in 2010.

We did not request a provider information return (PIR) prior to the inspection. A PIR is a form which asks the provider to give some key information about their service; how it is addressing the five questions and what improvements they plan to make.

Updated 8 November 2016

The inspection took place on 17 August 2016 and was unannounced. This meant that the provider and staff did not know we would be visiting.

We last inspected the service in May 2014 where we found that they were meeting all the regulations we inspected.

The provider was in day to day charge of the home and as such, there was no requirement for Parkfield Rest Home to have a registered manager in post under their registration with the Commission. The provider told us she was a non-practising nurse and had also completed catering qualifications.

The provider opened the home in 1984. She explained that the home had been up for sale for six years and they were “winding down.”

Two people were living at the home at the time of the inspection. They had lived at the home since 2002. Only part of the home was being used due to the small number of people living there.

We spent time looking around the home and found that not all areas were well maintained. In addition, there were shortfalls in infection control procedures. Risk assessments had not been carried out to assess risks relating to the premises and risk assessments for people were limited.

We had concerns with staffing levels since there was only the provider and senior care worker through the week to provide 24 hour care.

People told us that they felt safe. There was a safeguarding policy in place. This had not been updated in line with recent legislation and West Yorkshire’s reporting procedures. The provider had not completed safeguarding training and the senior care worker had not undertaken safeguarding adults training since 2006. There were shortfalls with certain aspects of medicines management.

Supervision and appraisals were not documented. The senior care worker had not completed any training since 2006 and there was no evidence that specific training to meet the needs of people who lived at the home had been carried out.

There was no evidence that people had consented to their care and support. During our inspection, it was not always clear whether people’s preferences were taken into account.

We checked whether people’s nutritional needs were met. The senior care worker informed us that one person required a soft diet because of an incident which had occurred in 2006. There was no evidence that advice had not been sought from a dietitian or speech and language therapist to make sure that the person was receiving a suitable diet. We noted that this person had lost weight in February 2016. There was no evidence that the person’s weight had been rechecked or action taken to reduce the risk of any further weight loss.

It was difficult to find out when people had accessed health care services because this was recorded in copious amounts of daily records. Staff had recorded that it was not necessary for people to see a dentist because they did not have any teeth and did not wear dentures. We considered however, that oral health checks should still be carried out to check there were no irregularities or oral health concerns.

We observed that some interactions between the provider and one individual were not person centred. In addition, the language and terminology used in daily reports did not always promote one person’s dignity.

Although staff informed us that people’s needs were met in a person centred way; there was limited information in both people’s care files to document this care and support. There were no formal arrangements in place for people to have their individual needs regularly assessed and reviewed. The senior care worker told us that this was ongoing.

There was a complaints procedure in place, however, this did not include all relevant information such as up to date contact details about who to contact.

There were no formal systems in place to obtain the views people. The provider said, “They don’t like formal systems. We are with them all the time.”

There were no systems in place to monitor the quality of the service. The provider informed us that informal undocumented checks were carried out. We identified serious shortfalls with the maintenance of records relating to people, the management of staff and the management of the service. Policies and procedures had not been updated in line with changes in legislation and best practice guidelines.

We had not been notified of certain events and incidents at the service which the provider is legally required to do. The provider was unaware of her responsibilities to do this.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. 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 a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

We found multiple breaches of the Health and Social Care Act 2008. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.