Park House

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• 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

We identified 3 breaches of the legal regulations in this key question. These related to safe care and treatment, premises and equipment and staffing. People gave mixed feedback on whether they felt safe at the service. Medicines were not always managed safely and at times, safeguarding referrals had not been escalated appropriately. At times, people's care plans were incomplete, or did not contain enough in to guide staff in supporting them safely. We observed there were not enough staff to meet people's needs; people's feedback confirmed this. The environment was not always clean and people were not always protected from the risks associated with infection prevention and control. Risks associated with people's needs were not always assessed or monitored appropriately.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People gave mixed feedback on the learning culture at the service. A person told us, “Some staff have listened and improved after issues I raised, but for some it falls on deaf ears” whilst another commented, “Yes, the care is improving over time. Changes in staff has improved things."

Staff knew how to raise concerns and record incidents and this helped keep people safe. However, staff told us they did not feel they were given opportunities to hear about ongoing risks, or changes to people's needs. All the care staff we spoke with told us the provider had stopped daily handovers. One staff member told us, "We would like a handover and then I would know if someone has changed, like their diet or something happened during the night.”

The processes in place to provide a good learning culture were not effective. We did not see evidence of regular supervision for staff to ensure positive feedback was received and any shared learning provided. There was evidence of staff meetings to allow for shared learning however, they were task focused. Processes were in place for staff to record and report any accidents or incidents. These were logged and reviewed by the registered manager to see if any further action was needed to prevent future risks. However, we found some examples where accidents or incidents had not been recorded through these systems, which prevented effective oversight. Furthermore, the registered manager did not undertake an analysis of any themes or trends arising from accidents or incidents to enable lessons learned. The management team told us the new electronic system would help with this, as it would create reports for better oversight and learning.

People gave mixed feedback in this area. A relative told us, "We were involved in care planning when my relative first came, but not since" whilst another said, "We have had no involvement in any plans."

Staff told us they had the information they needed to support people when they first moved into Park House. This included any information about people’s needs and preferences.

Partners told us referrals were often delayed as a result of some staff members being unclear on who was responsible for specialist equipment. Partners also told us the provider didn't always pass on relevant information regarding people's care needs when moving to or accessing additional services.

Preadmission assessments were completed prior to people moving into the service. However, these often-lacked detail. Care plans were not always devised in a timely way when a person moved into the service. This meant staff supporting people did not always have sufficient information to understand their needs. We saw for one person, 3 weeks’ after they moved in, staff had not completed several areas of their care plan, including their communication and sleeping needs. Referrals to specialist services were not always made in a timely manner.

We received mixed feedback from people regarding the safety of the service. One relative we spoke with told us, “My relative is safe I think, and they feel safe so that's the main thing” and “I'm very safe here, and the staff are always around.” However, others said, “My relative is safe I think, but there have been instances in the past with previous staff members” and “I feel safe, but don't like when people wander round and come into rooms and at night time, its worse.”

Staff we spoke with were knowledgeable about safeguarding and could describe situations and incidents that needed to be referred to in order to keep people safe.

We observed unsafe moving and handling practices. People were transferred in wheelchairs without the use of foot plates. This placed people at risk of their feet becoming trapped during transfers and increased the risk of them falling. We observed some positive interactions from staff with people however, staff did not always communicate with people effectively. We observed people spilling drinks on themselves due to not having appropriate equipment in place to support them with meals.

Whilst processes were in place to help safeguard people from abuse and neglect, staff had not always followed these effectively. Staff had reported various safeguarding concerns in line with local procedures. However, we found 2 examples where issues had not been reported to the local authority as required. One of these related to unexplained bruising. We also found that where staff had reported concerns correctly to the local authority, they had not always notified CQC about these concerns as legally required.

The people we spoke with were unable to articulate if they had been involved in managing risks. However, we saw evidence people had not been involved in contributing to and developing their care plans and risk assessments.

Staff were able to tell us about people and the risks associated with their care. They told us how they supported them safely. This included management of behaviours, mobility and when people may become distressed.

Risks were not always managed. We observed people not having access to a call bell in their own rooms and in communal areas. This prevented them from being able to call for assistance if they required it. A staff member was unable to tell us if a person needed to use footplates on their wheelchair. This information was detailed in their care plan, however, staff were either not aware of, nor were following this guidance. We raised this with the registered manager for further action.

Care records did not always evidence how people and their relatives had been involved in their own risk assessments. Where risks had been identified, steps were not always taken to mitigate the risks. For example, where people required repositioning to prevent skin breakdown, the care records demonstrated they were not always re-positioned in line with their assessed needs. We were not assured suitable handover processes were in place to ensure risks could be shared between staff. On one occasion, a person was at high risk of falls. Staff had sought further assessment and guidance from a fall's specialist. However, they had not fully acted on the guidance provided to help reduce the risk of further falls.

There was mixed feedback in relation to the environment. One person we spoke with told us, "My room is clean and tidy." However, another person told us, "Its clean but could look better."

Staff we spoke with acknowledged that there were issues with the environment and stated they had made management aware. One staff member said, “Needs a good lick of paint and especially on this unit. These kitchens in the dining rooms need changing and we just seem to collect lots of things all over the floors.”

The walls and floors were dirty with food and drink splashes on them and floors were sticky to the touch. Two of the bathrooms were out of order due to a previous leak and some people's bedrooms needed refurbishing. There was a malodorous smell within the home and sluice room which should have been kept locked with a keypad, to keep people safe, could be pushed open. This meant the room was accessible to people. The maintenance person took action to address this during our assessment. We saw a cup full of a green liquid stored under a sink cupboard which was accessible to people. Staff could not identify the liquid, and we asked them to remove this. This could have potentially posed a risk to people.

We saw throughout the building there were kitchenette areas. These contained fridges and cupboards with various foods and drinks accessible to people using the service. However, the registered manager was unable to demonstrate that potential risks posed to people, such as to those requiring a specialised or modified diet, had been fully assessed and mitigated if required. There was a small fridge in one of the kitchenette areas which needed cleaning. Foods such as butter had been decanted into separate dishes, but had not been dated, therefore staff did not know when it was out of date. Milk was also in the fridge which was 2 days out of date.

We reviewed mixed feedback on the quantity and responsiveness of staff. People told us, “There are sometimes enough staff, and some are more approachable than others and "I see more [staff] of a day and they are brilliant; night time, everyone seems too busy.” Others commented, “There are lots of staff in the day, but not at night time, they are not always quick to respond” and “There’s not really enough staff and we are still having issues with lazy staff.”

Staff we spoke with told us they felt there was not enough staff to support people in the home. Staff felt that the use of agency and permanent staff leaving had impacted morale and their ability to do the job effectively. One staff member said, “We are getting through with agency at moment; it is hard” and another said, “Staffing numbers are very bad and we use agency. Lots of staff have left.”

We observed staff on the units. However, people were being supported with personal care including bathing, after lunchtime, we were advised this was due to the staff not having time in the morning. One particular person we were informed would want their hair washing before going into the dining room for breakfast however, there was not enough time. We observed people being unsupervised in the dining area with the food trolley being left unattended whilst staff attended to people in their rooms. Some people were left with cold meals as no encouragement was provided.

Staff files were not all up to date. We found that other than the 3 most recent appointments, the remaining staff had not had their DBS checked for several years. For example, we found that some staff had a DBS from 2016 and they had completed a declaration form to say there had been no updates in 2019. There was no system in place to monitor DBS updates. Supervision records available were poor and did not demonstrate staff were receiving meaningful supervision due them being tasked based. There were no accessible overview of people's needs for staff who had not worked at the service before. There was a reliance on permanent staff to provide this information.

People spoke positively of the cleanliness of the home. They said, “It's very clean, always people around cleaning” and “Very clean, and always kept on top of.” However, some people felt that areas of the home required refurbishment. They said, “It's clean, but could look better. It just needs a bit of a tidy up” and “It’s very clean but needs to be decorated.” People confirmed that staff wore personal protective equipment (PPE) whilst providing support.

Staff told us there were limited cleaning products available including detergent. We were advised domestic staff were only able to clean the floor with water due to the cleaning facilities. One staff member said, “Very frustrated at this moment. Short of stuff; cleaning chemicals, hardly any toilet roll, no gloves.”

We observed there was limited personal protective equipment (PPE) including gloves and aprons. However, we were informed by the registered manager there was plenty stock available, but this was not visible in areas of the service so care staff couldn't readily access this. We observed an unclean environment including dirty floors, walls, doors and windowsills.

There was not an effective approach to assessing and managing the risk of infection in line with current relevant national guidance. People were not protected as much as possible from the risk of infection because premises and equipment were not kept clean and hygienic. Some furniture within the home was damaged which presented an infection and control risk. We observed various areas within the home that needed cleaning including communal kitchenette areas, fridges and bathrooms. The provider had identified the same concerns however, had failed to address these issues to ensure they did not happen again.

People and their relatives were not always aware of what medicines they were being given and what for. People told us, “I think they [medicines] are at right times, but I have no idea what I'm taking they just get given to me”, “I think they [medicines] are right, but I'm not sure what I take and when” and “We have had problems with my relative's medication. They are not being watched taking them, they were found on the floor.”

Staff that we spoke with about medicines told us they received support from the registered manager and deputy manager. However, we observed prescribed creams in communal shower rooms. We observed staff walking past and not putting medicines back in appropriate storage.

One person was prescribed an ointment to be applied for 7 days, which was stored in their bedroom. However, records were not available to demonstrate how this had been applied and whether it had been effective. Staff agreed to refer to the person's GP for further advice. The provider required nursing staff to have their medicines competency checked alongside their patch competencies. We identified this had not been completed for all staff. We were not assured all staff were competent in administering medicines safely. Protocols for 'as and when required' medicine did not contain detailed information to guide staff on when this needed to be administered. No records were available to verify the administration of topical creams by staff, which posed a risk of individuals not receiving the correct dosage. People who required their medicines to be administered covertly did not have the legal documentation in place in accordance with the mental capacity act.