Archived: Parkhill Nursing Home

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 inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe premises and equipment and safe staffing levels.

This service scored 47 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was limited evidence that lessons were learnt, and it was unclear how any learning from incidents was shared with staff. We found improvements in the recording and reporting procedure of accidents, incidents and safeguarding issues since the deputy manager had introduced a new monitoring system. This had yet to be embedded and demonstrated as effective. This new system could be further improved with the use of regular, detailed analysis of trends and actions taken to mitigate further risks and demonstrate lessons learnt and demonstrate a reduction in incidents and accidents.

Not all concerns found at our previous inspections had been fully addressed. For example, regarding the cleanliness, safety of the building and timeliness of care delivery. The insufficient staffing levels at the home meant that people were not always assisted in a timely manner and staff were not always present when help was needed and this placed them at the risk of harm. No improvements had been made to mitigate this risk since the last inspection.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The local authority was not commissioning new admissions to the home at the time of our inspection due to previous concerns about the safety and quality of the care provided. The local authority had been providing intensive support to the home in order to drive improvements at the home.

The deputy manager told us about their close working relationships with other services including the local GP service. Records demonstrated referrals were made to services where this was needed. However, we found advice given by healthcare professionals was not always effectively followed and had not always translated into good care for people. For example, our observations and care records viewed demonstrated one instance where a care plan, devised by a physiotherapist, was not being followed in relation to ensuring a person was assisted out of bed.

We found some shortfalls in how care was provided to people who had fragile skin and were at risk of developing pressure injuries. This included a lack of guidance for staff on how to manage people’s skin conditions and plans and records in relation to repositioning to prevent skin breakdown were inconsistent.

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.

People and their visitors told us they felt they were safe living at the home. One person told us, “I feel safe here and all my family visit.” One visitor told us, “[Name] has felt safe here, otherwise the family would have moved them out.”

Staff had completed training in safeguarding and the home was continuing to participate in the MAC process where the local authority had monthly oversight of any safeguarding concerns at Parkhill. Feedback from partners involved in this process had been positive. The deputy manager had improved the recording, monitoring and management of safeguarding incidents since they had taken their post at the home and they were able to demonstrate their knowledge of local safeguarding processes.

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.

People had a range of risk assessment and care plans that had improved since the last inspection and contained more personalised information. However, these were not always updated when needs changed or an incident occurred. Care documents did not always include detailed information to guide staff on how to effectively manage people’s needs. For example, one person had suffered 2 falls from their bed; however, it was not always clear what staff needed to do to mitigate this risk. Where people were at risk of becoming distressed or aggressive, care plans did not always provide robust and detailed guidance on how to reassure and distract the person effectively in order to reduce the risk of distress. One person, who may display distressed behaviour, was being monitored by an ancillary member of staff on their own as care staff were supporting another person. This placed the person at risk of not receiving appropriate care and the staff member, and other people, at the risk of harm.

There was limited evidence that people and families were involved in making decisions in relation to the management of risk. We reviewed a sample of people’s records, where reviews of care and documentation were recorded, and did not see evidence that people or their families had been involved in these reviews and there was no record of any input or feedback.

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

Some refurbishments of the home had taken place since the last inspection such as partial redecoration. However, we found continued concerns relating to the home’s environment. Some people’s bedrooms and communal areas needed further refurbishment, including an unattached wardrobe and radiator cover, incomplete foam coverage on hot pipes and we found no call bells were in situ where a sensor mat was used. The outside spaces were not always safe, clean and tidy and the lower ground floor outside patio was uneven and a trip hazard. We were able to access areas that may pose a risk of harm to some people, for example, an unlocked store room and sluice, and we found keys had been left in some bedroom medicine cabinets where medication was stored. We were able to access the outside garden space, which contained a partially filled pond, from the stairwell as the lower ground floor back door was not secure. The home continued to be unclean and malodorous in some areas; these included communal areas and some people’s bedrooms. We observed cleaning staff working hard; however, absences due to annual leave or sickness were not covered and therefore, the home was not appropriately cleaned during these times. Feedback from people and their visitors confirmed our findings relating to cleanliness and malodour in the home. One visitor told us, “The smells in the place [home] have been awful”.

Where people’s skin integrity was at risk and they required an air flow mattress to protect them from skin breakdown, we found one mattress was displaying a fault alert and we passed on our findings to the deputy manager who told us they would get this repaired. We mostly observed improvements in the manual handling practices of staff since the last inspection. However, we observed two people were transported around the home by staff without the use of lap belts, this placed people at the risk of harm.

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.

We found significant concerns in relation to the poor staffing levels, particularly taking in to account all the different areas of the home where people had bedrooms. It was evident there was not enough care staff on duty to respond to people’s needs and this was reiterated by people and their visitors whom we spoke with. One person told us, “It can be a long time before they [staff] come sometimes, especially at night.” Another person told us, “I have to wait if I use the buzzer because they [staff] are busy elsewhere.”

We noted multiple instances throughout the inspection where staff were not present around the home as they were assisting people in their room or providing personal care to individuals. The lack of sufficient staff had led to people not always receiving safe and suitable care and support in line with their choices and preferences, this included personal hygiene and meals. We observed on both mornings of our inspection where people had been up and waiting in the lounge for a long time before hot drinks and breakfast was served. For example, the breakfast trolley did not arrive on the ground floor unit until 10.20am on the second day of our inspection. We noted call bells were ringing for long periods and on one occasion, we activated a call bell on behalf a person who required staff assistance and we waited 18 minutes before seeking further assistance as no staff responded to the call bell.

We did not have access to the home’s dependency tool used to calculate safe and effective staffing levels; however, our site visits, feedback from people and visitors and our review of records clearly demonstrated insufficient staffing levels. We noted that when staff were absent from work, these posts were not backfilled and the burden of their work was then placed on existing staff, for example, cleaning and kitchen staff absences.

We had concerns about the efficacy of staff training due to the large amount of online training some staff were completing in one day. The provider’s training policy included modules that were stated as mandatory; however, these were not included on the home’s training matrix. Information provided to us at the time of the inspection, indicated there had been no additional training other than what was considered by the provider to be mandatory training. There was no condition-specific training, such as, skin integrity, diabetes or more in-depth dementia training, despite people living at the home with these conditions. We noted that not all staff had fully completed training relating to people with a learning disability as required. The provider sent us information after the inspection relating to additional training completed by some staff and details of some future training to be given to staff. We will review this information at the next inspection.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some areas of the home were not always clean and free from the risk of cross contamination. Windows were not always clean and bins containing offensive waste had not always been emptied in a timely way and had emitted a malodour. We found people’s toiletries were not always stored safely to protect the risk associated with cross infection. We observed some people had unclean fingernails, hair and feet and, although there was evidence in records that people were being supported with personal care, it was not clear these areas were being closely attended to. We also found limited evidence people were having regular and appropriate oral care. Many toothbrushes we checked had not been recently used, records of oral care were not being consistently maintained and some people we spoke with had unclean teeth. Wheelchairs and other equipment were not always clean and free from debris.

Prior to this inspection, we were aware the home had been awarded a food hygiene rating by the Food Standards Agency (FSA) of just 1 star in February 2025, this meant major improvement in food hygiene standards was necessary. We spoke with kitchen staff and found the required improvements had not been made in the 6 months since the FSA inspection and these concerns had not specifically been addressed in the home’s overall improvement plan.

Records demonstrated staff had received training in infection prevention and control and we observed staff wearing the necessary PPE when providing care and support. Audits were carried out to ensure the cleanliness of the home; however, we found widespread concerns relating to cleanliness during our inspection. People and their visitors expressed their concerns over cleanliness and infection control. One person told us, “The cleaners haven’t been in for 3 or 4 days, or the weekend, and the smell from the toilets has been dreadful. Bins haven’t been emptied, so it’s not been good.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People’s medicines and allergies were recorded accurately on medicines records. Systems were in place to ensure regular medicines were given safely and at the right time. Person-centred information was in place to support staff to safely give ‘when required’ medicines. Records to show when and where topical preparations such as creams were being applied were completed accurately. People who had thickening powder added to drinks because of swallowing difficulties were administered these safely and records were completed accurately. Medicines were stored safely and stock levels recorded correctly. When people administered any of their medicines themselves, personalised risk assessments were in place to ensure that they were able to do this safely. Medicines audits were completed at regular intervals to identify issues and drive improvement. Medicines incidents were recorded, analysed and learnt from. Detailed information was available regarding the incidents that had occurred and there was evidence of appropriate actions being taken.