Parkfield House Nursing 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 inspection 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 Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Lessons were learnt when things went wrong. There was a process for reporting and investigating accidents, incidents and complaints. The provider shared learning from these with staff and supported them to understand how to make improvements. Staff confirmed this, explaining they had discussed incidents during team meetings and training sessions. This helped to make sure improvements were made because of incidents and accidents.

People were supported with transitions between services. The staff worked closely with other professionals to make sure they had information about people’s needs. The staff had developed ‘hospital packs’ which outlined people’s health and communication needs. These were a useful summary made available during hospital admissions and for other external professionals. The home offered places for people to stay on a short-term basis. They had suitable systems to enable people to experience a safe admission and discharge. Some people had moved to the service following a hospital stay to help them rehabilitate and recover before going home. The staff worked closely with different therapists to support these transitions. This helped to make sure there were safe systems and pathways for transitions.

There were systems designed to help safeguard people from abuse. People using the service and their relatives told us they felt safe. Their comments included, “I definitely feel safe – there is always someone around’’ and “The staff are always friendly here.’’ Staff undertook training about safeguarding adults. They were able to tell us how to recognise and report abuse. There was information on display to help remind people and staff how to speak up and report any concerns. The provider worked alongside external organisations and the local safeguarding team to investigate allegations of abuse and implement protection plans to help keep people safe from further harm. These systems helped to safeguard people. The staff were able to explain what changes had been made following a recent investigation and how this had helped to keep 1 person safe.

The provider had requested legal authorisations where restrictions were in place. Decisions around these were made in people’s best interests and for their safety.

Risks to people’s safety and wellbeing had not always been assessed, monitored or mitigated. This meant people were at increased risk of harm. When assessments were in place, these were not always detailed enough to show how care should be provided to mitigate risks. Assessments had not always been updated following changes in a person’s needs, after weight loss and a fall. Failure to update assessments with these changes meant that plans were not always relevant or personalised.

The staff did not always follow good practice to keep people safe. For example, 1 person had been assessed as at risk of choking. Their plan stated they should be monitored when eating. This did not always happen. For other people who were at increased risk of skin damage, staff had not always ensured they were regularly repositioned to help protect their skin. Failure to assess, monitor and mitigate these risks meant that people did not always receive safe care and treatment.

The environment was generally safe and well maintained. The provider employed maintenance staff who monitored and responded to repairs. There was appropriate lighting, ventilation and heating. People had their own bedrooms which they could personalise with furniture and belongings.

The décor at the home included a range of homely features and personal touches which reflected the interests of people living at the service, including displays of their artwork.

People had equipment they needed to keep safe, such as hoists, specialist beds and specialist bath/shower equipment. These were regularly checked to make sure they were safe to use.

There were enough staff deployed to meet people’s needs and keep them safe. People told us when they used call bells, these were usually answered on time and the staff were available when needed. One person commented, “I use the buzzer, and the staff come fairly quickly.” The provider had allocated staffing levels based on people’s assessed needs. There were systems to help make sure staff were suitable when recruited. These included interviews and checks on their suitability. All staff received a comprehensive induction and training. Their skills, competencies and knowledge were assessed. The registered manager told us there was a low rate of sickness and good staff retention. This helped to make sure people were usually cared for by the same familiar staff.

Some parts of the environment had not been sufficiently cleaned. Some floors and handrails needed further cleaning. We also found some out of date food stored in a kitchen. We discussed these concerns with the registered manager who took action to address these.

There were systems designed to help prevent and control infection. Staff had training in these. The provider employed domestic staff to oversee cleaning and laundry and there were regular audits of cleanliness. Staff were provided with personal protective equipment (PPE) when needed. We saw they wore this appropriately. People told us the home was kept clean, and they were happy with this.

Systems were in place to manage medicines; however, records were not always person-centred. Care plans and protocols did not contain sufficient information for staff to support people who had complex needs. There was not enough information for staff about when to administer ‘as required’ medicines to make sure these were effective. Systems for managing prescribed topical medicines were not always robust enough to ensure safe care and treatment.

Staff administering medicines were interrupted and this was a potential risk to the safe administration of medicines. Medicines were stored safely. Staff administering medicines were trained to do so and had their knowledge checked. People were supported to self-administer their medicines when they wished to do so, and appropriate risk assessments had been completed. Staff told us they were supported by healthcare professionals who reviewed people’s medicines regularly. Healthcare professionals’ involvement was clearly documented in people’s care plans.