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 requires improvement. 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 three legal regulations in relation to how the provider ensured people received safe care and that risk was mitigated, the premises and equipment were suitable and safe and there were enough suitably trained and skilled staff at all levels to meet the needs of people living at the home.

This service scored 38 (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 demonstrate a proactive and positive safety culture based on openness and honesty. They failed to listen to concerns about safety, investigate or report safety incidents, and learn lessons to embed good practice.

Systems in place to oversee accidents, incidents and falls aware not effective and failed to protect people from harm. The provider had failed to address previous concerns relating to unsecured unused rooms being used for storage, highly flammable paints stored on site, and furnishings which were not properly secured. The checks carried out did not demonstrate the provider had identified or addressed these risks.

During the assessment, we raised several concerns relating to safety and asked the provider to complete their own checks. Whilst some issues were addressed promptly; implementation and learning were inconsistent. For example, a ground floor patio door was not secure and remained this way a week after concerns were initially raised. In addition, action on the use of a lap belt with a shower chair was delayed; the equipment was only ordered and expected two weeks later.

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 provider did not always ensure staff had access to the guidance they needed, and the advice given by partner agencies was followed. This included information from the speech and language therapy team about diets which needed to be modified to manage risk for people with swallowing difficulties and people who had dietitian advice to reduce risk associated with weight loss. People were confident staff would seek medical assistance when this was needed, and we saw staff contacted out of hours support for people if they became unwell. Staff communicated information about appointments people had to ensure these were attended.

The provider did not work effectively with people or healthcare partners to understand what safety meant to them and how it could be achieved. They did not focus on improving people’s lives or protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Concerns were not shared quickly or appropriately.

The provider failed to take timely action to address issues raised during previous inspections, including ensuring the environment was suitably safe and secure for people. These concerns are detailed further in the well led section of this report. We found people were subject to various restrictions, such as where they spent time and when they were expected to get ready for the day or go to bed. We were not confident the provider consistently took the necessary steps to keep people safe, including addressing moving and handling concerns where the incorrect equipment had been used. The issues we raised during the assessment had not been logged as safeguarding concerns or incidents.

People generally told us they felt safe and trusted staff to look after them, and families acknowledged improvements that had been made across the home. The local authority had previously been heavily involved in supporting the service to make improvements but had recently stepped back to allow the provider to maintain good practice. However, these improvements were not sustained and lacked robustness. Areas of highest risk were not appropriately prioritised to ensure people’s safety was maintained.

The provider did not work effectively with people to understand and manage risks. Staff did not consistently deliver care that was safe, supportive, and enabled people to do the things that mattered to them.

Risks were not well managed, and staff did not have sufficient guidance on the actions required to reduce risk. For example, several people who had recently fallen did not have risk assessments or care plans which reflected these concerns.

We observed unsafe moving and handling procedures placing people at risk of harm. People at risk of pressure sores were not repositioned as needed.

Specific risks for individuals were not always identified. For instance, 1 person who self-mobilised in a wheelchair was at risk of their legs becoming trapped under the wheelchair, but this had not been identified, and this risk had not been assessed. Similarly, staff did not have clear guidance on how to support people who chose to eat meals in bed safely, such as through maintaining an upright position or the frequency of safety checks whilst eating and we observed people were not always supported to eat meals safely to minimise the risk of choking.

Care plans and reviews did not evidence people or their families were fully involved in developing plans and making decisions about risk management. However, other parts of the care records, including communication notes, indicated families were involved in important decisions about people’s care.

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

The environment remained unsafe. General repairs and updates to the service, ensuring all bedrooms had access to hot water, and making sure radiators were covered and covers were securely fixed to walls were still needed. On the first day of our visit, we found windows without restrictors, including a communal first-floor bathroom where the window could be fully opened and 2 bedrooms where restrictors were not in good working order. Following our feedback, these 3 windows were addressed immediately. However, the provider failed to check all of the windows at the service and on the third day, a ground-floor office window had no restrictor and was open. We also found concerns about the security of a door leading to the patio and car park, which could not be locked. This was reported on the first day of inspection, but when we visited on the third day in the evening, the door was still unlocked, and staff were unable to secure it. This meant people were not protected from the risk of leaving the premises undetected or from others accessing the home. Although we were told the door had been secured, on the final day of inspection we continued to have concerns about the locking mechanism and how easily the door could be opened.

The service only had one shower chair, which did not have a belt to support people at risk of falls or slipping. There were no risk assessments for individuals who might need additional support when using the shower, and we were concerned about the safety of staff practices when supporting people who were fully dependent.

The provider did not ensure there were enough qualified, skilled, and experienced staff to meet people’s needs. Staff did not always receive effective support, supervision, or development, and teamwork was not consistently strong enough to deliver safe, person-centred care.

Staff were not always visible, and people consistently fed back concerns about the staffing levels and having to wait for support. Staff were often not available on the floor to support people, especially during the night.

The allocation of staff and dependency tool did not take into account the environment, particularly at night and the laundry and cleaning tasks care staff were expected to complete to support domestic staff. When staff were carrying out non care related tasks or having their breaks this reduced the availability of staff. This caused delays in people receiving their care.

Staff were recruited safely; however, they were not supported to carry out their roles effectively. Staff were insufficiently trained and had not received supervision and appraisals regularly.

The provider failed to ensure an appropriate mix of staff with the right skills and knowledge when allocating staff to shifts. This led to high agency use at night. Four agency staff members had worked at the service in the previous month without any record of an agency profile or induction. We observed poor moving and handing techniques and there was a lack of knowledge about people who required adapted diets. This meant we could not be assured staff working in the service were suitably skilled and knowledgeable to meet people’s needs.

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

Domestic staff worked very hard to keep on top of the cleanliness of the premises but had responsibilities for cleaning across three floors, as well as managing the laundry. We found some equipment, such as the stand aid, crash mats and sensor mats required deeper cleaning. We noted the odour across the service had generally improved, but there continued to be an unpleasant odour in the communal areas and hall on the first floor. The deputy manager advised the furniture needed to be replaced, and these matters were all part of the provider action and environmental plans.

Suitable policies were in place, and most staff had completed training in this area.

The provider made sure 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.

Medicines required to be given at a specific time or before other medicines, were given at the correct time every day. Person-centred information was in place to support staff to safely give ‘when required’ medicines. When these ‘when required’ medicines were given, the outcomes were assessed and recorded to ensure they were effective. Patches were applied and recorded correctly and were rotated around the body in accordance with the manufacturer’s guidance.

Medicines were stored safely and stock levels recorded correctly. Fire risk assessments had been completed for people who had emollient creams applied.

Care plans were up to date and contained personalised details about people’s medicines needs.

Medicines audits were completed at regular intervals to identify issues and drive improvement. Medicines incidents were recorded, analysed and learnt from.