Parkside Nursing Home Also known as Part of the abbey total care group ltd group of services

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 good. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, (including the management of incidents) the cleanliness, people being protected from the risk of neglect and the safe deployment and effectiveness of staff.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. Leaders did not listen to concerns about safety and did not always investigate safety events. Lessons were not learnt to continually identify and embed good practice. One person told us when staff hoisted them, they were ‘banged around and bruised.’

The provider had not been effective in identifying the areas of improvement in the service to reduce the risk of avoidable harm to people. For example, we saw from incident reports, people were frequently sustaining skin tears. The manager told us that the majority of skin tears related to the same person. However, on review of the records, in October 2025 there were 9 recorded skin tears, and these affected 5 people. In November, for the part of the month we received, 2 skin tears had occurred and the person the manager referenced was not either of these 2. There was no consideration in the analysis of these incidents, for example, whether staff needed updated training in moving and handling.

Where falls had occurred, there was a record individual people had been supported, and steps taken to mitigate the risk such as sensor mats put in place. However, the provider had not considered whether the deployment or numbers of staff needed to be reviewed. This meant opportunities to learn lessons from incidents and take action were missed.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not work well with people to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety. Where people had conditions that required closer monitoring, this was not always considered in the planning or delivery of care. This meant people were at increased risk.

People were not always protected from avoidable harm. Whilst staff were able to describe what safeguarding was, staff told us they did not feel they could not always speak up about their concerns. People and their families need to have confidence that leaders are acting in their best interests. When staff are empowered to speak up about concerns, and leadership actively listens and responds, it reinforces the message that the organisation prioritises the safety and well being of people.

The provider did not consistently act in accordance with the Mental Capacity Act 2005 (MCA). People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). As a result, some people were subjected to restrictions without the appropriate legal authority. We found that people’s movements were being restricted by using low beds, and there was not always authorisation in place for these restrictions.

However, people told us that staff were caring and respectful towards them.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to relating to people’s care and support were not being effectively managed this meant they were at an increased risk of harm. People’s choking risk assessments were not always accurate. The manager told us 7 people were at high risk of choking and although we observed they all received a modified diet, all of their choking risk assessments had been scored as ‘low risk’. This was despite a member of staff who completed risk assessments telling us, “If risk of choking increased, I update the risk assessment.” Although we observed people received the correct modified meals and were positioned correctly to have their meal, not all staff we spoke with accurately described how to assist a person if they were to choke. This meant that staff that did not know the person may not be aware of the risk. The manager has provided evidence that these risk assessments have now been updated.

Other areas of risk for people were not managed well including malnutrition. For example, according to their care plan, 1 person was required to have staff with them to encourage them to eat. However, we noted staff did not sit with the person when they ate and the person left most of their meal. We also noted they had lost nearly 4 kilograms in one week. Their care plan did not have a risk assessment in relation to their nutrition. A visitor told us, “I don’t think (person) is getting enough food. (Person) has gone downhill in the last 3 months.” We have raised this as a safeguarding to the local authority. We also identified the lack of robust monitoring for other people that had lost weight.

A person told us they had difficulties with their bowel movements. When we reviewed their care records, we found there were several days where staff had not recorded that they had opened their bowels. Between the 6 and 14 November 2025 (9 days) staff had not recorded any bowel movement for the person. However, there was no assessment in relation to the risk of constipation and no record of any action being taken in relation to this. This placed the person at risk of further risk of constipation. After the inspection the manager confirmed a risk assessment was now in place.

We observed 2 people were sitting in the lounge all day in their wheelchairs, with their hoists slings underneath them. Leaving a sling under a person can increase the risk of pressure injury.

However, where people needed to be referred to health care professionals this was being done including the Speech and Language Therapist, GP and dietician.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities supported the delivery of safe care.

The provider did not ensure the environment was safe or well maintained. A stairway in the communal area of the service where people’s rooms were located did not have suitable preventions to stop the risk of falling. Whilst we were at the service, a person at high risk of falls had been found by a member of staff on the stairs. The manager told us, “(Person) was on her own and shouldn’t have been. She had gone down the stairs, and the cleaner saw her. We are thinking of moving her downstairs now.” In another person’s care plan, it stated the person lived on the first floor, and they needed to be monitored closely as, ‘they are known to unlock the stair gate.’ However, given the provider was aware of the risk, action had not been taken to address this risk. Sufficient action had not been taken to reduce the risk to other people and there had been no wider consideration of the suitability of this area for other people in the service.

People’s hoists were all stored in a corridor and we observed 1 person catching their walking frame on the leg of the hoist. There were also sitting scales and a large standing hairdryer that had been left in the corridor and communal bathroom. These all created a falls risk. Prescribed topical creams were not stored safely and were placed in people’s unlocked cabinets in their ensuite bathrooms. This placed people at risk of accessing the creams and misusing them.

Following the inspection the provider took steps to start addressing some of the issues raised.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There was a mixed response from people and their relatives in relation to staff levels. Comments included, “Sometimes you have to wait, but if I use my bell, they are quite quick”, “Individual staff are nice, but there is not enough of them” and “There are days I am still in bed at 11:30.” One relative told us when they visit late in the morning, they often had to wait 35 minutes whilst their loved one was still receiving their morning personal care.

We observed that whilst there were sufficient staff in the communal areas, there were a lack of staff supporting people in their bedrooms. Between 11.39 and 12.25 no staff were present on the first floor despite there being people being cared for in their rooms and unable to use a call bell. Just after 12.25 a visitor pressed on a person’s sensor mat in error on the first floor and although staff came quickly, they left within a minute and went back downstairs. One person told us, “They check on me virtually never.” A relative told us, “(Person) is stuck upstairs and (person) isn’t checked on. I can be here for a long time, and I never see staff popping in.” During lunch, whilst people in the dining room were served their meals quickly at 12.30, people in their rooms were left a further 45 minutes before their meals were given to them.

The manager told us during the day they had 2 nurses (with 1 leaving at 15.00) and 6 carers that were rotered each day for 31 people. Staff told us up to 11 people required 2 staff for personal care, repositioning and transferring them from their beds. Staff fed back that there were not sufficient staff to support people. Comments included, “Sometimes we struggle. We have many double ups because this is a nursing home” and “Sometimes 3 or 4 people are ringing the bell. We are always running, running, running." In addition to this, staff told us that after lunch was served staff took their breaks in threes over a 90-minute period meaning that for this duration there were only 3 carers left on the floor. One member of staff said, “3 staff are taking care of 33 residents. Some of them can easily fall, some of them there is a risk of choking.” Another said, “It is a little bit tough. If anyone is asking [for support] at that time, we have to ask them to wait. We need to make sure 1 staff all the time in the lounge (if they need the bathroom), we have to ask people to wait. We have to wait for other staff to come back."

Whilst the majority of staff had completed the mandatory training, there were gaps in the updated clinical training for nurses. When asked, 1 nurse was unable to accurately describe how to assist a person if they were choking. Nursing staff completed risk assessments, but they lacked detail on how risks were mitigated. The lack of accurate recording of risk assessments was also picked up in clinical supervisions with nurses however sufficient action had not been taken to address this.

We noted the new manager had ensured the majority of staff had received a supervision however these were not always effective as we found multiple areas of concern around staff practice. There was a lack of assessment of competency or observation to ensure that training was understood and implemented safely.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

People were at placed at risk as the provider had failed to ensure good infection, prevention, and control practices. We found there was a strong smell of urine in several areas of the service, particularly near or in people’s bedrooms. A representative of the provider told us they also identified this on the day of the inspection. One person’s mattress had a strong odour of urine, indicating that cleaning practices and bedding management were not consistently effective. The manager told us this mattress was being replaced.

The general cleanliness of the service was poor including thick dust build up in communal areas, handrails, the lift, flooring and people’s bedroom walls. A relative told us, “It could do with a spruce, its tired looking. It (cleaning) slips at weekends.”

Where maintenance alterations had been completed within the service including door catches, the wood was left exposed making cleaning more difficult. The sluice room sink areas required cleaning and there was a commode bowl stained in one of them. In one of the communal bathrooms, the shower unit was covered in limescale. Communal bathroom cupboards had clean continence pads out of the packet. The hand sanitizer in the downstairs corridor was empty. The manager confirmed some of these areas had been addressed since the inspection.

Staff responsible for cleanliness within the service was not adequate to ensure all areas were covered and kept clean. One member of staff said, “They could do with more cleaners, we have 2 every day but only 1 on the weekend.” Infection control audits were taking place, but they were not effective in identifying and addressing all the concerns.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.