Parkside

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 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 care and treatment.

This service scored 41 (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 had not implemented a culture where staff learnt from incidents, accidents and when things went wrong. We were told there had been no accidents and incidents for the past year. However, we identified the service had information recorded regarding a fall within a person’s care records and the person was taken by paramedics to be checked. This incident had not been recorded for the provider to monitor for actions taken, lessons learnt and how to mitigate risk. The registered manager told us they sent duty of candour letters to people. However, the provider did not have records of who the duty of candour letters had been sent to. This meant there was no oversight nor analysis of incidents and concerns to investigate, report thoroughly and to identify themes and trends. The provider was not always proactive in addressing and ensuring learning from incidents, accidents and when things go wrong. Therefore, lessons could not be learnt nor shared to continually identify and embed good practices. Opportunities for learning and the chance to improve the service were missed.

The provider did not always work with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. A manager told us they would share relevant information to support people with a smooth transition to other services. In addition, they told us they would obtain relevant information to ensure the service could actually provide the care for the person. People had health and care passports, and one person had a personal emergency evacuation plan. However, we identified for one person the medicine records on the health and care passport were not the same as the person’s individual support plan. We were told people had food and fluid charts and information relating to these needs was not recorded on the health and care passports. Therefore, the care records were not accurately updated and lacked sufficient information to support and maintain safe systems of care. This meant people were not always supported with safety and continuity of care.

The provider did not always work well with people and healthcare partners 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, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. Relatives told us their loved ones were safe. However, our inspection found the safeguarding processes did not meet the expected standards. The provider recorded concerns on a safeguarding log. However, we identified the guidance for one person was stated as, ‘monitor client’ and ‘review risk assessment.’ There was no information recorded on how staff could be supported to action this to support the person, nor who would have oversight of this. There was no information recorded on how information was shared with the wider team to keep people safe. The provider did not have an effective system in place for reviewing and investigating safety and safeguarding incidents and events that go wrong. We report more on this in well-led.

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. The provider did not take appropriate action to mitigate risks.Whilst staff told us information relating to risks were included in the care plans, our inspection found this did not meet the expected standards.Care records did not contain up-to-date information and did not cover all potential risks. For example, one person had severe health needs. The provider had not completed specific risk assessments for these health needs to support staff in identifying changes in the person’s needs to mitigate risks. A person was at high risk of malnutrition but there was no guidance in place to support staff on how to monitor any changes in the person nor was there evidence of professional input. There were no risk assessments for a person who had dizzy spells and lost their balance often. For another person, their care records stated the person should not be left unsupervised while in the bath or shower as there may be a risk of them falling or slipping. However, there was no risk assessment in place for this person in relation to falls nor guidance on how mobility was to be monitored. Risk assessments were not in place for people who used emollient creams which can pose a fire risk and risk of slipping. For one person, we identified they used a paraffin-based skin product flammable cream and there was no risk assessment in place for this. This meant people were at risk of harm, and staff were not provided with the appropriate guidance to support people safely.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care and care records did not contain important information to support the delivery of safe care. We identified a risk assessment contained guidance for staff to record the bathing temperature with the care plan notes for the person. However, the temperature was not recorded within the care plan notes. We identified within another person’s care records, information was not recorded on how to check the water temperature and where this was to be recorded. The individual care records for a person who required support with mobilising, informed staff to test the smoke alarms weekly. There was no guidance to support staff how to test the alarms and where to record this. However, we identified in one person’s care records staff were guided to keep the floor dry and clear of obstacles to prevent slips and trips

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. Records related to recruitment did not demonstrate a robust process. There were employment gaps identified within the staff files and not all employment checks had been completed. Moving and handling and medicine competencies checks had not been actioned. We were told only one spot check and observation had been actioned this year. The spot check records subsequently submitted by the provider did not evidence who had oversight and monitoring of the issues identified. Staff supervision records were not fully completed and did not demonstrate how staff were supported to professionally develop. Whilst the provider submitted an updated training matrix, we were not assured there was oversight of the training records. We identified a member of staff had nailcare training however this was not evidenced on the training matrix. We report more on this in Well-led.

The provider assessed and managed the risk of infection. Relatives told us staff wore gloves and personal protective equipment (PPE). Staff told us they were trained in using of PPE, hand washing, using gloves and wiping down doors and handles.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. There was inconsistent recording within people’s care records, we identified gaps within the medicine administration records (MARs) and there was no evidence of how ‘when required’ (PRN) medication was monitored and reviewed. This meant we could not be assured medicines were administered safely as prescribed. This has placed people at risk of harm. For one person, we identified there was no information recorded on the risks or side effects of penicillin. The audits did not identify these issues. We report more on this in Well-led.