Purley Gardens 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. This is the first assessment for this re-registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 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.

Managers and staff described how incidents, concerns and complaints were recorded, reviewed and used to support learning and improvement. Accidents and incidents were analysed to identify themes and actions were taken to reduce the risk of similar events reoccurring. Staff said they felt able to raise concerns and these were discussed during handovers and meetings.

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.

There were arrangements in place to assess people’s individual needs, wishes and risks to their safety, before admission and to coordinate care with community-based health and social care professionals. These systems supported continuity of care and helped timely discharge from hospital.

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.

People were protected from abuse and improper treatment, and staff understood their safeguarding roles and responsibilities. People and relatives said they felt safe using the service. One relative told us, “I feel my [family member] is very well looked after and protected from harm at the home.” Another added, “I have never witnessed anyone being mistreated at Purley Gardens. I feel confident my [family member] is kept safe at the home.”

Managers and staff knew how to recognise and report abuse and were able to articulate how they would spot signs if people were at risk of abuse or harm. A staff member told us, “Ive had safeguarding training, so I know what constitutes abuse and what I need to do if I witness it, including reporting any such incident to the person in-charge.” Managers worked proactively with the relevant agencies, when a concern was raised, and took appropriate action to safeguard people from further risk.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed Dols within the service. We found that people were only deprived of their liberty when there were legal authorisations in place to do so to keep people safe.

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.

Systems were in place to ensure risks people faced were routinely assessed, monitored and reviewed. People’s care records contained sufficiently detailed information for staff to follow. This ensured risks to people were reduced, so people remained safe when taking part in activities of daily life. Managers and staff were fully aware of these risks and the steps they needed to take to mitigate or safely manage them. Staff described how they balanced risk with independence, enabling people to take positive risks and do tasks they wanted to do for themselves whilst remaining safe. Risk assessments and management plans were reviewed at regular intervals and updated according to reflect any changes in people’s needs.

The provider did not always ensure the care homes environment was suitably decorated or adapted to a consistent standard to meet people’s needs.

The provider did not ensure the care homes environment was ‘dementia friendly.’ The premises were clean and spacious, and people’s rooms were personalised. However, we found the provider was not always adhering to best practice guidance to ensure the environment was decorated and adapted to meet the needs of people living with dementia. For example, there were not enough easy to understand pictorial signage displayed throughout the care home. This lack of signage impacted how people experienced and navigated their environment. A relative told us, “For those residents who are living with dementia and have a degree of independence I think they struggle with orienting themselves sometimes.” Communal areas also lacked colour contrasting doors and walls. Most of the carpets and wallpaper in communal areas were patterned and there was a lack of distinction between different areas of the care home. In addition, while some people living with dementia had a memory box positioned near their bedroom door, many did not. A memory box is a container that holds objects of reference that are important to a person, such as photographs or ornaments. These visual clues help people living with dementia orientate themselves and identify rooms that are important to them, such as their bedroom.

We discussed these issues with managers at the time of our assessment who were aware the environment needed to be suitably decorated and adapted to make the care home more dementia friendly. Managers agreed to seek appropriate advice and guidance from reputable sources about how to make the care home ‘dementia friendly’ as part of the providers ongoing programme to refurbish Purley Gardens. We saw work to refurbish the entire care home had commenced and managers assured us the process would take approximately 9 months and be completed in the Spring [2027].

People told us the care home was a safe and comfortable place to live. The environment was free from unnecessary slip or trip hazards which enabled people to move freely and safely around the home. Safety systems and equipment people needed was in place and serviced at regular intervals to support the safe delivery of care. Staff had clear guidelines available to help them deal with emergencies.

The provider made sure there were enough qualified, skilled and experienced staff, but how they were deployed in the care home needed to be improved. Staff received effective supervision and development, but they did not always have their overall work performance appraised as they should.

Staffing levels matched the staff duty rota on our unannounced site visit to the care home. People and relatives told us the care home was usually adequately staffed and spoke positively about their approach. One relative explained there could be a delay in staff responding to answer activated call bells, but most people and relatives said staff usually answer them quickly. One person said, “Staff usually come as quickly as they can whenever I press my call bell alarm to request help.” Throughout this assessment we observed staff were usually visibly present and quick to respond to people’s questions and requests for support.

However, we observed the lower ground floor was not staff by any nursing or care staff for 10 minutes during the service of lunch on one occasion. In addition, during this same period a call bell alarm went unanswered for well over 5 minutes. Most staff told us the floors/units they usually worked on were usually adequately staffed. However, several staff who worked on the lower ground floor/unit consistently said they often felt rushed and over stretched at peak periods of activity, especially during mealtimes. One staff member explained, “We must deliver people their meals and assist some people to eat and drink, so it’s not always possible for us to stop what we are doing to support someone who is requesting assistance at these busy times. We need more staff on the floor to help at mealtimes.”

We discussed this issue with senior managers who confirmed they had reviewed staffing levels in the care home and developed an action plan to improve how staff were deployed throughout the care home at peak periods of activity to mitigate the risk of floors being unstaffed in the future.

The service was no longer over reliant on agency staff whose numbers had been significantly reduced following a recent staff recruitment drive. With fewer staff vacancies people were now receiving continuity of care from more permanent staff who were familiar with their needs, preferences and daily routines.

Staff had opportunities to reflect on their working practices and to identify any further training, learning or support they needed. This included having regular individual and group meetings with their line managers and fellow co-workers. However, staffs overall work performance had not been appraised annually, contrary to the providers own staff appraisal policies and procedures and recognised best practice. Managers and staff confirmed this. One staff member told us, “I have regular 1 to 1 meetings with my line manager but I haven’t had an appraisal for many years. I don’t think staff appraisals were a priority for the last manager we had here.”

We discussed this issue with managers at the time of this assessment who acknowledged annual appraisals of staff’s overall work performance had not been conducted at regular intervals in recent years. Managers agreed to ensure all staff had their annual overall work performance formally appraised by the end of 2026.

The provider had a programme in place to ensure staff completed their mandatory training. Staff received a mix of ongoing e-learning, in-person practical and theoretical training, and competency-based assessments. Relatives told us staff working in the care home seemed knowledgeable and skilled. One relative explained, “I think all the nurses and carers here are well-trained and competent in their roles.” Staff confirmed they received all the training they needed to perform their roles and responsibilities well. One staff member told us, “The training we receive here is always relevant and is constantly being refreshed.” There were effective systems in place to ensure this training was regularly reviewed to ensure staff stayed up to date with best practice guidance.

The provider operated safe staff recruitment practices. Managers undertook the necessary pre-employment checks required on staff that applied to work at the service to ensure they were suitable to support 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.

People lived in a clean, hygienic environment. Relatives told us the care home was clean and staff managed the risk of infection spreading. One relative said, “Staff always wash their hands and wear the appropriate personal protective equipment [PPE].” Another added, “Staff do wear PPE and it is always available in the residents’ bathrooms.”Staff had received food hygiene and infection control training and had access to resources and equipment to help them reduce infection risks, which included adequate supplies of [PPE].

The provider made sure medicines were safe, well-managed and met people’s needs, capacities and preferences. They always involved people in planning, including when changes happened.

The service’s medicines systems were well-organised and safely managed. Medicines stocks, balances and records showed people consistently received their medicines as prescribed. Care records contained detailed guidance for staff about how people needed and preferred their prescribed medicines to be administered. Detailed risk assessments and protocols for the administration of prescribed medicines were in place to guide staff. Staff received medicines training and their competency to continue managing medicines safely was routinely assessed by their line managers. There were regular internal audits of the care home’s medicines practices, so any medicines errors would be identified and managed quickly.