Green Park 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.

The service was in breach of legal regulation in relation to safe care and treatment, medicines and Infection prevention and control.

This service scored 56 (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 continually identify and embed good practice.

Processes were in place for managing accidents and incidents. Staff completed accident and incident records, and this was followed up in daily notes and updates in care plans. Learning from incidents was captured within clinical governance meetings with clear actions, training and lessons learnt. The manager completed a monthly audit of accidents, incidents and trends. Where people were at risk of falling, sensor alert mats were in place.

Safeguarding referrals were completed without delay and were referenced within incident reports. A complaints process was in place, all complaints received were investigated openly.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Feedback from visiting professionals was positive with comments including, “Communication from the service is great and they are responsive to people changing needs.”

Admission processes were in place with initial assessments completed for new admissions and processes in place for when people attended hospital.

Staff showed a good understanding of the risks to people’s health and wellbeing and how to mitigate these. Referrals were completed to the appropriate professionals following any changes or risks identified to people.

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.

Systems in place safeguarded people from the risk of harm and/or abuse. Staff had access to safeguarding and whistleblowing policies and procedures.

Staff were trained in safeguarding and were able to demonstrate their knowledge and the actions they would take to ensure people were kept safe. One staff member stated, “Safeguarding is discussed regularly, and we observe and report any concerns.”

Safeguarding referrals were made in a timely manner and records of referrals to the Local Authority were available.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were completed using PCS (electronic care planning) system. People’s risk assessments were fully reviewed and safely managed ensuring people were protected from risk of avoidable harm. Records were updated following accidents and incidents or when new information regarding people’s care needs came to light.

The provider had a business contingency plan. This covered plans in the event of an emergency and backup procedures were in place.

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

We observed parts of the service posed a risk to people. This included within some areas, trailing wires from electrical bed cables within people’s bedrooms, x7 broken toilet seats to ensuite bathrooms and damaged light fittings. The storage of slings within people’s bedrooms was not safe and posed risks to people accessing their ensuite bathrooms. The provider was responsive to the concerns identified; new toilet seats were ordered and installed without delay and all other remaining risks were actioned.

Systems were in place to check the safety of the environment and equipment this included quarterly health and safety meetings and yearly audits, however, the concerns identified were not identified within the systems in place. The provider had access to a maintenance team, and systems were in place to log jobs required for completion. The manager discussed a review of the system to ensure there were no delays in maintenance requests, and to ensure the most urgent work was completed without delay.

A fire safety policy and procedure was in place plus a home’s emergency plan. This included emergency evacuation procedures and a suitable place of safety in the event of evacuation. PEEPS (personal emergency evacuation plans) were in place for people and included people’s evacuation plans, photograph and all relevant information including medication prescribed.

All required safety certificates were available including six monthly checks of the lift and lifting equipment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support, supervision and appraisal, however, where there were people with high numbers of unwitnessed falls, staffing levels had not been adjusted to ensure there were enough staff to meet the need of people. We have asked the provider to review staffing levels within a particular unit of the service.

We received mixed feedback from people and visitors about staffing. One relative said, “I don’t think there are enough staff all the time, at times there are only 2 staff members, and some residents need hoist care, so no one left with other residents.” Another relative said, “Daytime there is never any problems, night time doesn’t seem to have as many, if there has ever been a problem its always happened of a night, so I don’t think there is enough overnight.”

Within one of the units a service user having frequent falls was referred for escalation to multidisciplinary teams for input. Consideration for 1:1 care was reviewed and not upheld due to the persons medical conditions.In response to this, we asked the provider to complete a review of the staffing levels to this unit.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The manager had made recent changes to cleanliness and environment since starting in post however, we identified parts of the service were not always clean. In particular within kitchen areas or within people’s bedrooms. Some of the furniture required cleaning and some bedding required replacement. The provider was responsive to the findings and actions were implemented without delay.

Infection prevention audits were completed, and control policies were in place, however they did not identify areas of improvement observed during the assessment. Staff had completed infection prevention and control training. Staff had access to good supplies of PPE, in particular gloves and aprons. We did make a recommendation for more liquid hand gel to be available on the units.

Procedures relating to barrier nursing were in place, however, improvements were required as observations did not evidence barrier nursing in practice was being followed on the first day of the assessment. This was reviewed by the manager and improvements were observed by the second day of the assessment.

There were processes in place to support the safe and effective management of medicines including policies and procedures, however, we identified some areas in need of improvement.

The use of covert medication was not always clearly documented. This posed a risk of medicines being administered incorrectly. For some people, there was insufficient evidence of best interest decisions or Mental Capacity Act (MCA) assessments for the use of covert medications, including a lack of involvement from relatives.

We reviewed the records for one person who was prescribed time-sensitive medications and identified these were not consistently administered as prescribed with many gaps. A risk for the person not taking their medication was an increase in falls, this had not been reviewed or discussed with the persons GP, placing the person at risk of avoidable harm.

The labels on some prescribed medications was difficult to read therefore, we could not be assured the medication was correct. The provider responded without delay and contacted the pharmacy.

Some people were prescribed PRN (as required) medications. Records in place evidenced regular review. We found for some people pain assessment tools were utilised to evaluate people’s pain. We recommended the use of the tools was reflected in PRN protocols to support staff decision making with administering medications.

Processes for ordering medications was in place, and this was being followed. Medication audits were completed; however they failed to identified the concerns found during the assessment. Staff had received medication training and competencies were being assessed. Clinical supervisions took place to ensure staff knowledge was up to date. This supported staff within their roles to deliver safe care and continue to develop professionally.