Parklands Court 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

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

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. One staff member told us, “We have guidelines for falls, incidents and accidents, we monitor any incidents and accidents. If an accident occurs, for example a fall, we will review and update care plans and risk assessments, we then complete an incident or accident form on our internal system, this then alerts the manager. We will then continuously monitor for any bruising or injuries. Also, we have a duty of care to inform relatives and the safeguarding team. We would also call emergency services if needed.” The management team had a system in place to ensure incidents and accidents were logged and actioned. The provider’s system to review accidents and incidents was effective. We saw lessons learnt from incidents and accidents were analysed and shared with the staff team during handovers and team meetings which meant there was a consistent approach to future learning.

The provider did not always work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety or ensure effective systems were in place to ensure there was continuity of care. For example, we saw 1 person was prescribed medicines for the management of Epilepsy. However, there was no Epilepsy care plan in place to enable staff to provide safe, consistent care in relation to their Epilepsy. There were processes in place for people moving into and out of the service. For example, preadmission assessments were completed prior to people moving into the service. There was a process in place for people leaving the service. The manager told us about the systems in place to facilitate discharges from the service. They said, “We handover to the new service. We send a transfer letter and complete a body map. Also, we make sure the person has enough medication to last them 28 days, we send a profile and discharge summary. Most importantly we communicate with the new service.”

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. One person told us, “I feel safe, if I didn’t feel safe, I would tell my relatives.” Another person said, “Everything feels safe to me; there is no reason to feel unsafe. People and staff are lovely; they do what they can for you to help.” Staff listened to concerns about safety and reported safety events. We saw evidence that safeguarding concerns were logged and actioned in a timely manner and referrals were made to the relevant professionals. The provider also had a protection of vulnerable adults’ policy in place and staff had a good understanding of safeguarding. A staff member told us, “We have safeguarding training. Safeguarding means we have a responsibility to protect people and keep them safe.” The provider had established systems to support staff to raise concerns, and staff had received training in protecting people from avoidable harm. 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 found appropriate legal authorisations were in place when needed to deprive a person of their liberty. Staff had a good understanding of DoLS and had had received DoLS training.

The provider did not always work well with people to understand and manage risks. Staff did not always have access to the information needed to provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks were not consistently assessed and recorded which meant risks were not always managed. For example, 3 people had a profiling bed and air flow mattress. We saw mattress checks were completed daily. However, there was no detail recorded that related to specific mattress settings, so the checks did not ensure people’s mattresses were set correctly to meet their needs. This missing information in people’s care records placed them at risk of receiving unsafe care. Since our assessment, the manager responded to our feedback by updating the relevant documents with mattress settings.

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.

For example, systems in place to check mattresses were not effective as they had not identified that specific settings had been agreed and checked. This meant that people could be at risk of pressure damage. However, we saw that other environmental and equipment checks were effective. The manager shared their maintenance and grounds audit with us. We saw that health and safety and fire safety checks took place to ensure the home was compliant with health and safety regulations. The environment was clean.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. We received mixed views regarding staffing at the service. One person told us, “I don’t think that there is enough staff, I think that there should be more.” Another person told us, “I suppose there is enough staff except for weekends.” Relatives expressed a more positive view. They told us, “The staff have the time to sit down with people.” Another relative told us, “When I visit there is always staff about. There is always somebody in the lounge and staff are caring.”

Our observations in communal areas showed there were periods of time where people were observed to be at risk of falls due to attempting to stand from chairs when no staff were present to support them. The lack of staff presence at these times, placed people at risk of harm from falling. Staffing levels were determined using a staffing tool, with staffing levels being set by the provider. This was based on the number of residents, and not the needs of residents. Since the assessment the manager has responded to our feedback by increasing staffing levels. We will check this change has been effective at our next assessment. Recruitment records showed relevant checks had been carried out prior to staff commencing their employment, to ensure they were safe to work with people. The provider had established systems to support staff to receive adequate skills and training. The provider’s training records showed staff had completed training relevant to their role, and this was up to date.

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.

One person told us, “It is very clean and tidy. They are always dusting and cleaning.” Another person told us, “It is nice and clean here.” A relative told us, “It is nice and clean, and my loved one’s bedroom is always nice and clean. I have seen staff wearing gloves and aprons when I visit.” Personal Protective Equipment (PPE) was available for staff to use. We saw the home environment was clean and tidy. The provider had an infection prevention policy in place and infection control audits were completed regularly and these were effective. The provider had established systems to ensure staff had received training in infection prevention and control. We observed staff wearing PPE when serving food. We also observed staff encouraging people to wash their hands and use antibacterial hand gel prior to eating food.

The provider did not always make sure that medicines were managed safely. Stock levels of medicines did not always match the medicines administration records which meant we could not be assured that people had consistently received their medicines as prescribed. One person’s care plan referred to a medicine that was ‘not tolerated’. This information was not reflected in the person’s medicines records which placed them at risk of receiving this medicine incorrectly. However, where people used pain relieving patches to help manage symptoms, patch application sites were recorded appropriately. We reviewed protocols used where people were prescribed medicines ‘as required.’ We saw clear instructions on their use. This meant staff had guidance in place to know when these should be given. Prescribed creams were correctly stored. Homely Remedies were in use with a policy to support their use and stock checks for these medicines were accurate. Staff we spoke with understood how medicines were prescribed, supplied, administered and stored safely. Staff told us they were trained to administer medicines. We saw that competency checks had been carried out to ensure they were safe to do so, and medicines audits were completed. Records confirmed staff had received training and had their competency checked regularly.