Park House

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 remained requires improvement. This meant people were not always safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment and medicines management. Although some areas of improvement remained incomplete and required embedding; we found improvements at this assessment and the provider was no longer in breach of this regulation.

This service scored 59 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to improve and embed good practice.

People and their relatives felt their concerns were acted upon by the staff. The majority of people we spoke with felt the management team were approachable and available.

Risks to people were used to learn and improve the quality of care. For example, where people had sustained an injury, following a fall. We found the records, along with actions taken by staff at the time were improved. The service used these records to monitor for themes and trends and share learning with the staff team. Flash meetings were held, to share findings with staff, and records from staff meetings showed incidents were discussed. We found the management team were open and transparent and worked hard to drive improvements at the service. The management team clearly understood their responsibility to report incidents to the relevant authorities.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always assess 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 acknowledged there were some shortfalls in the information contained within the 'critical information' section of people’s care plans. Where emergency information, life history, wishes and feelings was recorded, this had not been effectively used for planning across all areas of peoples’ care plans. Improving the quality of these records would ensure care plans fully identified a person’s needs.

Three people living at Park House were in the ‘younger adult’s’, service user band. At the time of our inspection, the provider was not registered with the CQC for this band which is required to enable them to provide care for younger adults. The provider has subsequently submitted a notification to add this required banding

The service worked well with external professionals to ensure people received timely support for their identified health and social care needs. For example, where equipment was required, or a review needed to be completed of a person’s cognition.

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 with relevant agencies quickly and appropriately.

The majority of the people and their relatives we spoke with told us they or their family member felt safe; however, one person expressed feeling isolated at the end of a corridor, which was due in part to the ongoing refurbishment. We shared their concerns with the management team to review. One person said, “I feel safe and fortunate to be here, as people are so kind.” A relative told us, “I think my family member is safe, we’re happy with the choice of home.”

The management team understood their responsibility to ensure incidents were reported promptly to the local authority and the CQC. There were processes in place for the management team and staff to review incidents. Staff meetings and individual supervision sessions allowed staff to reflect on what was working well, and what could be improved at the service. This meant the tools used would ensure improvements could be made and any learning could be shared widely across the staff team.

There was a provider policy for the duty of candour. This policy guided the service to tell the person, or where appropriate their advocate, when something had gone wrong. We reviewed complaints that had been made and saw this policy had been followed by the management team.

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

Although we saw communal areas were effectively staffed and supervised to reduce any risk to people, call bell response times were identified as an issue for some people and their relatives. Feedback indicated this was noticeable when staff were occupied elsewhere. In relation to call bells, one person said, “As I’m in bed all the time, there are times when something comes up and I’ll use my buzzer, and no one comes. I use it twice a day maybe, they can be quick or at times it’s been an hour or more. I’ve pressed several times and eventually someone will come, and I’ll challenge them over the waiting time. They’ll [staff], make up an excuse that they’ve been busy.” A relative told us, “It does vary, depending how busy the staff are.” Other people were more positive, one person said, “I’ve only used it a few times and three of the staff came really quickly.” We raised our concerns regarding call bell response times, and people’s experience with the management team. They advised they used regular audits and review of processes to ensure any changes to dependency or staffing could be made. We were assured by their response.

Risk assessments relating to the health, safety and welfare of people using the service were completed. This ensured plans were in place to support people to manage risks. For example, where people were at risk of falls, reviews had taken place to mitigate further risks to the person and to maintain their safety.

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

The building was in the process of being refurbished to ensure people were kept safe from the risk of harm. The directors provided an updated service improvement plan, detailing the significant ongoing refurbishment taking place. This plan would ensure Park House was a safe and pleasant environment for people. We acknowledged the improvements which had already been made and will review the impact of these once they have been completed as planned.

Flooring throughout the communal areas and some people’s bedrooms had been replaced. However, some flooring and carpets, for example in communal bathrooms and some bedrooms posed a risk of infection, due to being worn and with unsealed edges being able to harbour bacteria. The service improvement plan shared with us by the provider, incorporated timescales for completion of the remaining works.

Bedrooms were being refurbished with consent from people and their relatives. The management team had completed a full review of all rooms, with redecoration taking place in order of need. The management team had processes in place for monitoring the safety of the environment and documented the regular checks of the building. We saw areas of identified risk had been promptly resolved to keep people safe.

The provider had invested in a new sensory room, to engage and stimulate a person’s senses and provide a calming environment if people exhibited distress. The lounge and gardens had been improved, ensuring people could relax in comfort, and enjoy time with their visitors. One person said, “I like to sit outside, or I’ll come and sit in the bar lounge, if I need a change of scenery.” A staff member told us, “The building has really improved since the refurbishment began, we can already see the positive changes.”

The service had improved their safety measures in the event of a fire. Required actions had been taken to achieve compliance with the deficiency notice issued by Nottinghamshire Fire and Rescue Service. People had personalised personal emergency evacuation plans in place, which had been reviewed and updated as their needs changed. Corridors and exit doors were clear of all blockages to allow people and staff to safely egress in the event of an emergency. Staff knew how to respond in the event of an emergency evacuation. For example, if a fire alarm sounded, staff understood where people would be supported to move to as the designated safe space.

The provider made sure there were enough qualified, skilled and experienced staff, who received regular support, supervision and development opportunities. However, we found the staff team did not always work effectively to provide care that met people’s individual needs. For example, where people expressed concerns about the timeliness of staff responding to their call bells or of waiting to be assisted in the morning.

The service used agency staff when required and took measures to keep the consistency of these staff, by using the same agency. Feedback regarding agency staff was mixed, with some people feeling they may not to be as patient with them. One person said, “They need more staff generally. I notice I wait longer at weekends as they definitely have less staff on. Some agency staff can get snappy as they haven’t got the patience with me.” We reviewed staffing rotas and could see that the management team used a dependency tool to ensure staffing levels were adequate. Where any agency staff had been found not to uphold the high standards expected from the provider, this had been raised with the relevant agency as a concern.

Whilst in conversation with one person in their bedroom, they had pressed their call bell to be moved, due to pain. After 10 minutes, there was still no response. As the person was in evident pain now, a member of the inspection team went to alert a staff member, who responded promptly. The lack of timely response left this person exposed to the risk of harm and experiencing distress.

People and their relatives we spoke with were generally happy with staff competency but the majority mentioned feeling some additional staff were needed, and weekends were mentioned as a concern. Another person said, “They could do with a few more staff, as sometimes I’m not assisted to get up till 10am, as I need two carers. The majority of staff are fine and do their job ok.”

Other people were more positive about staffing and the staff team’s approach. One person said, “I find they’re marvellous.” A relative told us, “They seem shorter on staff on a few days but seem to manage. The staff here are brilliant, and I find the care very good.”

Safe recruitment processes were followed. Staff had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider and management team had robust action plans in place to ensure the environmental refurbishment plan and timescales were achieved. This plan ensured that infection prevention and control was a priority at Park House.

People and their relatives were happy with the general cleanliness of the home and most found the laundry service acceptable, although one relative gave negative feedback about this. A relative told us, “The domestic team are lovely. My family member has bed baths as they can’t sit for a shower. We do their laundry ourselves now though, as things got lost previously.” One person said, “I’m kept clean and well dressed. My bedroom is very nice; they have good cleaning staff who come in.”

Staff had received training in infection control, how to put on and dispose of personal protective equipment and how to keep people safe in the event of an infection outbreak.

We saw the kitchen was managed in a hygienic way by a knowledgeable staff team, to ensure people were not at risk of food borne infections. The most recent check from the food standards agency had rated the service 4 stars in May 2024. Staff had received food hygiene training and were able to explain actions they took to reduce the risk of food borne infections.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning how they would like their medicines to be managed, including when changes happened.

At our last assessment, the provider was in breach of regulation 12, in relation to the safe storage of medicines. At this assessment, we found improvements had been made, and the provider was no longer in breach of regulation.

People gave us their feedback in relation to medicines management. We spoke with 3 people who had capacity, who told us that sometimes their medicines would be left with them to take in their own time, unsupervised. One person told us, “Sometimes staff leave them with me in a little cup, and I’ll take them with my drink and give it back to someone later.” We also observed one person being given their medicines covertly in a beaker at the dining table and not being supervised to take them. This left the person and others potentially at risk of harm from ingesting medicines not intended for them, or of the person not taking their medicines as prescribed. We discussed this with the management team, and whilst we acknowledged the need to encourage independence with medicines, the management team investigated our concerns promptly. Learning from these concerns was shared promptly with the clinical team, and enhanced supervisions were completed with relevant staff. We were assured by the approach of the management team.

Medicines management at Park House had improved significantly, with clinical staff explaining how the new clinic room had improved their practice and processes.

The provider ensured that medicines and treatments were safely stored and managed. The new clinic room was kept organised and tidy by the clinical team.

Staff involved people in planning and remaining independent with their medicine’s regime. People were supported to receive their medicines in a safe way. Prescribed creams were now stored safely, and not in people's bedrooms as previously.

Medicines were received and disposed of safely. Staff involved in handling medicines had received recent training. The registered manager ensured staff were assessed as competent to support people with their medicines. Fridge storage temperatures were checked daily. Controlled drugs were stored and monitored correctly by the nurse in charge.

Where people were being provided with their medicines covertly, we saw there were appropriate best interest decisions in place to support this.

We observed staff supporting people with their medicines in a discreet way, explaining what the medicines were and asking how they were feeling before they provided their medicine. People's preferences for taking their medicines were clearly recorded on their administration charts.