Park Lodge Residential Care 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 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 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 culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Accident and incident forms had not always been completed correctly. This meant control measures had not always been identified or implemented to reduce the risk of re occurrence and lessons were not learnt. For example, when a person had a fall because they could not reach their cup of tea, staff completed the incident form and to reduce the risk from happening again stated person should ask staff for assistance. This demonstrated staff did not consider other control measures such as moving the table closer or providing a more suitable table.

Some incident forms were not fully completed, which meant the provider could not be assured incidents had been appropriately reviewed, analysed, and acted upon to reduce the risk of similar events occurring again.

There was no consistent oversight of incidents and accidents. The provider had a system in place to identify themes and trends through monthly reviews of incident and accident forms; however, these reviews were not completed consistently. This meant potential patterns or recurring risks may not have been identified promptly.

The provider had a system in place to share information with staff, via staff notices. These were reminders to staff on what not to do and staff were asked to sign these. We found that some were not signed by all staff members. This meant the provider could not be assured that all staff had read and understood important information to keep people safe.

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 have an effective system in place to ensure vital and up-to-date information about people could be readily shared when they were admitted to hospital. Information was not available in a single, summarised document, such as a hospital passport. The management team told us they were working to improve this. In the meantime, staff would provide ambulance crews with paper copies of the relevant information held by the service.

However, we found allergy information was recorded inconsistently across different documents. Some care plans and risk assessments were not person-centred and contained incorrect information. This meant the provider could not be assured that hospital staff received accurate and up-to-date information about people’s needs and risks to support safe and continuous care.

Notes from meetings with healthcare professionals, and requests for support relating to people’s declining health, were not stored centrally and were often handwritten in people’s care plans. This meant important information was not consistently organised or readily accessible. This increased the risk changes in people’s health and professional advice may not be effectively communicated or acted upon.

Health and social care professionals were complimentary about working with the provider.

People generally felt safe and staff understood their safeguarding responsibilities. However, safeguarding systems were not always effective because concerns identified within the service were not consistently recognised, acted on or reported appropriately.

Relatives and people told us they felt safe. A relative said, “I feel [person] is safe. We have never had any concerns about abuse of any kind.”

Staff told us they felt people living at the service were safe and knew how to raise safety concerns within the service. Staff were also aware they could report concerns externally to the local authority or CQC. The provider had competency checks in place to check staff’s safeguarding knowledge. We found these were not always completed.

We found concerns had been raised with the local authority. However, during our inspection we identified shortfalls in care delivery which required us to raise safeguarding concerns with the local authority. For example, it was alleged 1 person was not supported with their oral hygiene. This had been reported to the management team; however, the concern had not been acted on or reported to the appropriate external agencies as required. This meant the provider could not be assured safeguarding concerns were consistently recognised and responded to effectively.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care services, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. Appropriate applications had been made in accordance with DoLS, which helped protect people’s rights.

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

Some people had alarm mats in place to alert staff in the event of a fall. We found these had not been fully risk assessed. This meant the provider could not be assured the alarm mats were suitable for each person and any associated risks had been identified and managed effectively.

Records showed risk assessments in place were not always person centred. For example, 1 person’s falls risk assessment stated they used a zimmer frame. This was inaccurate as the person was supported to move by 2 staff members using hoist.

We observed 1 person’s nails were covered in dirt. Management and staff told us the person could become anxious during personal care, and this had previously been identified as a concern. However, this was not identified as a potential risk within the person’s care plan and had not been risk assessed. Staff did not have clear guidance about how to manage the person’s anxiety while supporting them to maintain their personal hygiene safely and consistently. This meant known risks relating to the person’s personal care had not been appropriately assessed or managed, increasing the risk that their hygiene needs would not be consistently met. We raised this with the local authority safeguarding team during the inspection.

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.

At the time of the inspection, the provider did not have an up-to-date fire risk assessment in place.

We observed some fire doors did not close fully. The documentation in place stated these concerns had been previously raised and addressed; however, some fire doors seemed to not fully close at the time of our onsite visit. We raised these concerns with the local fire service and the local authority safeguarding team.

In response to our feedback, the provider introduced temporary control measures pending completion of the necessary work.

Other environmental risks were not always managed effectively. For example, 1 piece of equipment used to support people to mobilise had not undergone the necessary checks to ensure it was in safe working order. The provider responded to our feedback and organised for the equipment to checked and serviced.

We observed the kitchen to be clean, however the seal on the fridges was broken. The temperatures were not checked and some of the food in the fridge was not dated when opened.

Staff told us they knew to report concerns relating to the environment to the management.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

Minutes of staff meetings were not always recorded. This meant the provider could not demonstrate what had been discussed, whether important information had been shared, or whether agreed actions had been followed up. Records showed some staff had not completed most of their required training, and some staff were supporting people with their manual handling needs before they had been formally assessed and signed off as competent to do so.

Staff competencies were assessed; however, some competency documentation had not been signed. This meant the provider could not be assured that staff had been formally assessed as competent to carry out their roles safely.

Staff did not have access to specialised training appropriate to their role. For example, some people required support with their mental health needs and some people displayed distress or anxiety due to their medical conditions. Some staff did not complete the necessary training and there was no plan in place to ensure this would be completed. This meant the provider could not be assured staff had the necessary knowledge and skills to understand and respond appropriately to people’s individual needs.

Staff did not have access to the provider's current policies and procedures. Previous policies had been replaced with an online system, but the provider had not ensured staff were able to access it. The provider therefore could not be assured staff had access to current guidance to support them to carry out their roles safely and consistently.

The provider did not always assess or manage the risk of infection.

The provider did not consistently monitor water temperatures. This meant they could not be assured that temperatures were maintained at safe levels to minimise the risk of legionella bacteria developing. The legionella risk assessment identified outstanding actions; however, these had not been completed. The provider responded to our feedback and arranged for the required work to be carried out.

Staff confirmed they had access to personal protective equipment, such as gloves.

The service appeared to be clean at the time of the inspection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

We found some creams in people’s bedrooms were not dated when opened. This meant staff could not be assured that the creams remained within their recommended period of use and were safe and effective to administer.

We found staff had incorrectly signed 1 person’s medicine administration record because they had not recognised that the cream being applied was different from the cream prescribed. Staff were also unaware that a prescribed spray was available to support the healing of the person’s skin. This increased the risk that the person would not receive their prescribed topical medicines as intended.

When medicines were prescribed to be taken ‘when required’, person-centred protocols were in place to guide staff on when they might need to be administered. However, we found 1 person’s PRN medicine was sometimes administered earlier than permitted by the prescription. This increased the risk of the person receiving the medicine at unsafe intervals.

Records were in place to show that risks were considered for people using higher-risk medicines such as flammable topical preparations.

We observed safe medicine administration and staff asking for consent before administering medicines to people.