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 good. At this inspection the rating has been assessed as requires improvement. This meant people were not always safe and protected from avoidable harm.

The provider was in breach of legal regulation in relation to safe care and treatment.

This service scored 44 (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 approach to safety based on openness and honesty. Lessons from events were not always learnt to continually identify and embed good practice.

Some people and their relatives felt that concerns were not always acted upon by the staff, although they felt the management team were approachable and available.

Risks to people were not always used to learn and improve. For example, where people required increased checks following a fall where they had sustained an injury. We found the records of these, along with actions taken at the time of the incident were spread over multiple documents. This made it challenging for staff to understand what risk mitigation was in place. Therefore, the service could not effectively monitor for themes and trends.

However, we found the management team were open and transparent and wanted to drive improvement at the service. The management team understood their responsibility to report incidents to the relevant authorities. Following us raising these concerns, the management team implemented robust monitoring plans for events such as this.

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.

We received mixed feedback from people and their relatives regarding the continuity of care at Park House. One relative told us, “We have raised concerns, but nothing gets done, the services are not joined up with the GP.” Whilst one person was more positive about their care and said, “We get good care, if I am concerned, I will see the manager.” Another relative gave positive feedback, “The GP came in to train 3 nurses for my family member, for a specific condition. They were very happy to do training and in supporting my family member with this.”

The service worked 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 quickly and appropriately.

The majority of people and their relatives we spoke with told us they felt safe. One person said, “I feel comfortable, the staff are fantastic. The staff are helpful.” Whilst another person said, “The staff know me really well.”

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.

Risk assessments relating to the health, safety and welfare of people using the service were not always completed. This meant plans were not always in place to support people to manage risks. For example, where people were at risk of falls, follow up assessments were not always in place to mitigate further risks to the person to maintain their safety. Communal areas were not always effectively supervised to reduce risk to people.

The majority of people we spoke with had concerns about the use of their call bell; either a bell not working, waiting long times for a staff response or people trying not to use theirs at peak periods. This left people at risk of harm.

In relation to call bells, one person said, “Sometimes, after lunch there are only one or two staff around, and we have to wait longer, but this is okay.” Whilst another told us, “I don’t know where the call bell is, I just shout them.” We also received feedback from people who expressed concerns around not being supported to access their toilet when they needed to, and the negative impact this had on them. One person said, “They do not respond quickly, I have waited an hour to go to the toilet. I need help to get to the toilet now.” A relative told us, “I was here recently, and we had to wait 2 hours for my family member to be taken to the toilet after we had pressed the buzzer.” Other people were more positive, one person said, “Yes, they come quick enough.”

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

The building was not well maintained or refurbished to a high standard to ensure people were kept safe from the risk of harm. The director explained how the building required significant refurbishment to ensure this was a safe place for people.

Flooring throughout the service posed a risk to people living with mobility needs or a falls risk. The service showed areas of significant disrepair, with internal damp areas and heavily stained, worn flooring. The service was in need of decoration throughout.

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 not been promptly resolved to keep people safe.

One staff member told us, “My main concern is the building to be honest, it’s not letting us shine as a team. It’s overlooking the actual care. People have to get to know and trust us and the building is the first thing you’re going to see. We don’t need a palace, just something safe and lovely for our residents.”

The home was unsafe in the event of a fire. Minimal actions had been taken to achieve compliance with this. Corridors and exit doors were not clear of all blockages to allow people 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 explained where people would be supported to move to as the designated safe space. However, the overall fire safety risk management for the service was not robust and left people exposed to a risk of harm in the event of an emergency.

We discussed our concerns with the directors, who gave assurance of their plans to significantly invest in the environmental improvements needed. We shared our concerns over fire safety with Nottinghamshire Fire and Rescue Service. They visited the service on 27 January and 17 February 2025. On the second visit, they found the service had made improvements and were ‘broadly compliant.’

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, we found they did not always work effectively to provide safe care that met people’s individual needs.

We observed a poor lunchtime experience for people, made more challenging for the staff team due to the dining room being closed for repairs. This meant people had to eat their lunch in a cramped space next to the lounge. There were 4 tables set for 14 people. There were no tablecloths or cutlery set out. Space was limited and staff struggled to manoeuvre people using wheelchairs to their table. There were not enough chairs so 6 people were seated on sofa chairs to eat their dinner from side tables. These tables were high and the chairs were low making it difficult for people to see their meals or be able to eat their lunch comfortably. Some people reported that the staff had very little time to support them with eating or just chatting.

We raised our concerns regarding the lunchtime experience and the lack of support for people from staff. The management team were responsive to our concerns and on day 2 of our inspection had moved the dining space into a temporary position within an unoccupied area of the building.

Staff skills and competency been regularly assessed to ensure staff could meet individual people’s identified health and care needs. People gave a mixed response when asked about their opinion of staff training and skills. One person said, “Some staff are well trained, but bank staff do not seem to have the same skills.” Whilst another person said, “Yes I do think the staff are well trained.”

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 member’s safety to work with people.

The provider did not effectively manage or ensure the risk of infection was a priority at Park House. The service was unclean and unhygienic. Due to the lack of refurbishment, the service was unable to be effectively deep cleaned to ensure people were protected from the risk of infection.

The management team were aware of the challenges a poorly maintained environment placed on the ability of the domestic team to adequately deep clean. These significant shortfalls left people exposed to the risk of infection through poor infection prevention and control practices. One relative told us, “It’s not very clean. I stuck to the floor in my family member’s bedroom, the floor is sticky.” Another relative told us the light above their family member’s bed was broken, creating a potential risk of harm.

Areas of the home were in a state of disrepair meaning it could not be cleaned effectively. The home was visibly dirty in parts, with stains and malodour observed on some pressure cushions, flooring and furniture. The provider completed a full audit of the cushions and furniture following our inspection and arranged replacements, but these shortfalls had not been identified prior to our inspection.

We discussed our concerns regarding infection prevention and control practice with the management team. They gave assurance this would be addressed as a priority and supplied an action plan linked to their service improvement plan. We will review this at our next inspection.

Staff had received training in infection control, how to put on 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 did not always make sure that medicines and treatments were safely stored and managed. Staff did not always involve people in planning and remaining independent with medicines.

People and relatives gave mixed feedback in relation to medicines management. One person told us, “Yes I do get it near the time I am supposed to take it.” Whilst a relative we spoke with shared concerns around previous missed medicines for their family member. One person was more positive and said, “Yes, I take it when I need it.” Another person said, “I know how to ask for medication.”

People were not always supported to receive their medicines in a safe way. Prescribed creams containing medicine were found to be accessible in multiple people's bedrooms. The risk of these being applied to the wrong people or a person ingesting these was high. We asked the management team for these to be stored securely after the first day of inspection. We checked and this had been completed when we returned on day 2.

The clinic room was untidy, with prescribed items stored at ground level. We discussed our concerns with the management team, and they advised they were planning to move the clinic room during the refurbishment. This would allow for a safer and tidier storage space.

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, asking how they were feeling before they provided their medicine. People's preferences for taking their medicines were clearly recorded on their administration charts.