Archived: Parkhill Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of one legal regulation in relation to how the provider ensured good governance and oversight at the service, ensured people received safe, good quality care and the requirements of regulations were complied with.

This service scored 36 (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 shared vision, strategy, or culture based on transparency, equity, equality, human rights, diversity, inclusion, and engagement. They did not demonstrate an understanding of the challenges or the needs of people and their communities.

The provider failed to prioritise action in response to concerns raised by visits from the Food Standards Agency and to address breaches of regulation identified by CQC. We found several repeat areas of concern, indicating the provider was unable to embed or sustain improvements needed to ensure people’s safety and quality of care. However, improvements in the management of medicines had been maintained.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support, or who embodied the culture and values of their workforce and organisation. Leaders lacked the skills, knowledge, experience, and credibility to lead effectively and did not demonstrate integrity, openness, or honesty.

The provider had not ensured there was a registered manager in post for several years. However, they had arranged for a member of the senior management team to register with CQC, and the application had been submitted. The provider gave assurances the manager registering with CQC would be permanently allocated to manage Parkhill and would be present at the service 5 days a week. At the time of our visit, people, families, and staff were not aware of these plans and told us they rarely saw anyone from the senior management team within the service.

People, families, and staff spoke very highly of the deputy manager. One person told us, “[Deputy manager] is good and always makes time for me and answers any questions I have.” We observed the deputy manager was visible within the service, knew the people living at Parkhill, and supported staff with hands-on care when needed.

People did not always feel confident they could speak up or their voice would be heard.

Although most people told us they had no complaints, we continued to receive consistent concerns about staffing. This issue had also been raised at our previous inspection, but there was no clear evidence the provider had taken robust action to address it. No recent complaints or whistleblowing concerns had been recorded. Meetings with staff and people had been held by the deputy manager since our last visit.

The provider did not consistently value diversity within its workforce or promote an inclusive and fair culture. Efforts to improve equality and equity for staff were limited.

Staff worked hard and often took on extra shifts beyond their contracted hours to cover gaps in the rota. The deputy manager told us this was voluntary and staff were not pressured to do so. However, staff said they felt a sense of responsibility to people and wanted to ensure there were no gaps in care.

The provider did not have clear roles, responsibilities, systems of accountability, or effective governance. They failed to act on reliable information about risk, performance, and outcomes, and did not share this securely when appropriate.

Quality assurance systems were inadequate. Oversight and audit systems were carried out by different staff and senior managers, but these were ineffective and did not identify multiple concerns, such as issues with the premises. Although monthly reviews and care plan audits were in place, they failed to highlight inaccuracies, missing information, lack of detail, or that care plans were not consistently followed. Leaders had failed to recognise through their own quality assurance monitoring that people were continually placed at serious risk of harm.

The provider did not consistently understand their duty to collaborate and work in partnership to ensure services operated seamlessly for people. They did not always share information or learning with partners or work together to drive improvement.

There was some progress in helping people living at the service to engage with the community. For example, the activity worker told us they were working with a local school, and a recent Christmas fayre had been successful, with people running some stalls. However, further work was needed to embed regular links with the community.

Staff worked with other agencies, but there was not always evidence advice given was incorporated into care plans or followed.

The provider did not prioritise continuous learning, innovation, or improvement across the organisation and local system. They did not encourage creative approaches to deliver equality of experience, outcomes, and quality of life for people, nor did they actively contribute to safe, effective practice or research.

Learning did not take place to support improvement and there was a lack of knowledge by leaders in how to do this. When things went wrong, good practice was not reviewed and embedded. Staff had not been equipped with the knowledge, skills and experience to lead on the delivery of consistently good care. The systems in place to support the running of the service were not effective. Feedback was not sought from people, relatives and staff to support learning, evaluate improvement and lead innovation.

There were multiple audit and check systems were in place, but these had failed to identify significant issues found during inspection. Where concerns were identified, they did not always lead to timely action.

For example, records from flash meeting included a prompt to ensure oversight of agency staff and their induction process. However, we found four instances where staff profiles and induction records were missing. Oversight of agency staff had been a concern at previous inspections and placed people at risk because the provider could not confirm agency staff were suitably skilled and knowledgeable.

Accident and incident records showed the deputy manager had some oversight and ensured medical support was provided when needed. However, there was limited evidence of full analysis at manager and provider levels.