Parkhill 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

People were not always kept safe and there were six breaches in regulation. The breaches included the management of safe care and treatment, the need to safeguard people, the safe management of premises and equipment, the lack of appropriate systems of governance and oversight, insufficient staffing levels of appropriately trained and skilled staff and a lack of robust and safe recruitment. People were placed at risk as accurate records and information about needs were not being maintained and there was a lack of provider oversight in all aspect of safety at the service. Safeguarding and lessons learnt were not always robust and numerous instances of poor practice which placed people at risk of avoidable harm were noted. The premises had not been effectively adapted to meet people’s needs and timely action in response to environmental shortfalls was not always taken. There was not always enough staff, the high use of agency staff created a lack of consistent care, and staff were not always robustly recruited.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s experience of the learning culture of the service was mixed. Some families told us the service was responsive to feedback but records and observations did not demonstrate this was consistently the case. For example, where there were areas of concern that had been raised with the service prior to our inspection we found limited evidence to indicate these had been addressed or resolved, for example people having access to drinks in their bedroom or shortfalls in moving and handling.

Staff told us that communication about changes including people’s needs worked well. However, evidence did not support this and staff did not have good knowledge about changes in people’s needs and records and care plans were not always accurate, detailed or in place. Leaders told us they were working with the support of the local authority to make changes in the service. Following our feedback the managers moved their office to ensure they were more readily visible and available within the unit.

Suitable processes were not being followed to ensure lessons were learnt. There was a lack of consistency in the frequency and quality of checks and audits completed and these checks were not always identifying areas of shortfall and had not led to any areas of change being embedded. For example, although processes for reviewing and analysing accident and incidents were in place, it was not evident that these had been completed every month; where these were in place these failed to demonstrate any robust analysis or action to ensure lessons were learnt. For example, where a person had fallen, these processes for oversight did not ensure that appropriate action to mitigate risk through reviewing care plans had been taken. The provider lacked oversight of what audits had been completed.

People and families generally felt staff would seek medical assistance if this was needed. However, two people told us they felt their concerns about their physical health were not taken seriously. Whilst staff had made contact with medical professionals about these matters, it was not clear that records reflected the impact these matters were having on people, for example when managing an acute or ongoing health complaint. People commented they had requested input from physiotherapy but had been told by the service this was not available by staff and access to audiology and dental care was not always quickly provided. One person told us “Very helpful people [staff] come in to look after us, and the doctor always comes quickly if we need one.” However, records did not always reflect the medical advice was implemented by the staff team and people were receiving the support they needed in line with the advice given.

Due to staff shortages and the high use of agency and it was evident that risk was not being well managed. Permanent staff felt that concerns were being addressed but recognised improvements were needed. Leaders were aware of shortfalls in identifying and responding to people’s needs and were working with stakeholders to address these concerns.

Partner agencies had a number of repeated concerns about how people were being supported and felt action to address concerns had not been taken as quickly as needed. They noted that referrals were made to services such as nursing team and dieticians but it was not clear that advice was always followed and there was a lack of contemporaneous records and provider oversight.

There were suitable processes and policies to check people’s clinical needs. However, these had been ineffective in demonstrating risk were identified and timely action taken. A robust approach to managing risk was not demonstrated and it was not evident that policies and action plans were always being followed. There was a lack of oversight for the safe management of people’s changing needs.

People had not always been safeguarded from risks of avoidable harm and there were multiple safeguarding investigations which were ongoing at the time of assessment. Several people and family members thought the service was safe although raised concerns about the high use of agency staff and staffing shortages. However, three people raised concerns that they did not feel safe and that a person was going into their room at night. One person commented “It’s the third time this has happened now. It must be recorded somewhere because I keep telling staff. I can’t relax.”

Staff were not always able to demonstrate they had a good understanding of their responsibilities under safeguarding, particular with regard to the agency staff. The management team acknowledged these difficulties and were working to be visible within the unit and direct care given to enable people received the support they needed. However, this was not consistently done and was not sustainable as a long term solution.

During the assessment the inspection team observed multiple occasions where people not treated kindly as adults, given choice and were left in undignified and degrading positions including the lack of access to continence support and including being placed at risk through unsafe moving and handling. We raised a number of safeguarding concerns to the local safeguarding team following our onsite visit.

Policies and procedures were in place but it was not clear staff had the understanding and training needed to understand their responsibilities. Paperwork did not demonstrate robust investigations and curiosity about incidents and lessons learned had not been effectively embedded across the service. People were placed a risk of harm through areas of poor practice.

People and families told us they had not been involved in discussions about the management of risk. Risks were not being managed well, staff did not understand people’s risks including dietary needs and moving and handling and potentially unsafe incidents were observed during the inspection. Considerations about action to reduce risk were not always taken in a timely way and equipment to reduce risk such as alert monitors, call bells and crash mats were not always in place or used appropriately.

Staff told us the information about people’s needs and risk was communicated in handover, and they had got to know people’s needs from induction. Feedback from staff was not reflective of our observation and we identified some gaps in staff knowledge and ability to support people to manage risk. Following our first day of inspection the manager implemented an overview of people’s needs for the agency staff.

During our site visit, inspectors observed several examples where people’s safety was not maintained. This including how people were supported with moving and handling and repositioning, the food they were given and how medicines were provided.

The service had moved to an electronic care planning system but not all care plans and risk assessments were in place and reviews were not always being completed regularly or when needs changed. There was a lack of evidence of systems for oversight to ensure people’s needs were being met.

The environment was worn and did not always reflect people’s preferences or needs, including to support people living with dementia to remain as independent as possible. The safety of the building was not always maintained placing people at risk. Families raised concerns that some areas of the home smelt very strongly unpleasant. People told us they were unable to go outside to the patio due to unsafe railings.

Staff felt the environment needs some improvement. One staff member told us, “The home has gone downhill.”

During the site visit we found areas of the home were cluttered, used for storage, presented entrapment risk and areas of the home not secured that should have been, such as the storage of cleaning chemicals. We observed peoples’ bedrooms lacked personalisation; there was a lack of signage and input to ensure the premises was dementia friendly; and various area of the home, including people’s bedrooms had strong malodours even after they had been cleaned.

There was not enough evidence to demonstrate effective oversight of the environment. Management daily walk rounds were not always happening to identify risk and did not demonstrate robust action to address any areas of shortfall. Maintenance checks were in place, however, there were not always consistently completed, and failed to demonstrate timely action had been taken, for example in response to issues with the temperature of water being identified.

There was not enough staff available to meet people’s needs, and there were delays in people accessing care needed such as with their continence needs. Pressure relief was not always being given as directed. There was a high use of agency staff and feedback from people and families was that this was where the primary shortfalls originated. One person told us, “The staff are not really interested. They should really go round the patients, and they don’t. There’s a lot of agency staff and they just stand about. They never get involved with the patients. Half of them need waking up.” A family member commented, “I think they are short-staffed but they do their best. I think they’ve been interviewing for staff.”

Staff told us they were very busy and most felt that the home would benefit from additional staff to provide support. Permanent staff did raise concerns about the high use of agency staff, and their ability to communicate and meet the needs of people. The management team recognised the need to recruit permanent staff who knew people and had the right skills and training in order to improve the consistency of care given.

We observed staff did not have sufficient knowledge of people, understand their needs, and were not able to effectively communicate with people. Although some staff spoke kindly to people, this was in contrast to staff who did not interact or show any interest in people. We observed multiple examples of poor staff practice.

The management team told us that the home was staffed to the appropriate dependency levels. However, the high use of agency and lack of process to effectively deploy permanent staff within the home was a challenge. There was a lack of assurance that robust action had been taken in response to feedback from stakeholders about staffing levels. Recruitment processes were not completed robustly and action identified from the previous inspection had not been embedded. There was a lack of oversight and process to induct agency staff on shift.

People were not being offered the opportunity to maintain good personal hygiene and oral care and people were not always dressed in clean clothing. People and families commented the home was generally clean but areas were in need of redecorating.

Staff told us there was a programme of redecorating and bedrooms were starting to be addressed. One staff member commented that it was difficult to get on top of some areas of the cleaning, Some staff felt that not all staff employed had a good understanding of infection prevention and control.

During our site visit we observed people were not washed, their nails and hair were not always clean and clothes were often dirty. People were left in continence aids for long periods of time and personal care before meals times was not always promoted.

Domestic staff worked hard to keep the home clean. Audits had been completed but it was not evident that these were completed on a robust and regular basis. Shortfalls in infection prevention and control identified by external stakeholders and through the assessment were not reflected within the provider’s own systems.

Care plans did not always have up to date, personalised information about how to support people with their medicines. People told us they were not always safely supported to self-administer their medicines and medicines risk assessments were not always completed for people who were administering their own medicines. Records for adding thickening powder to drinks, for people who had difficulty swallowing, were inconsistent and not always completed. Therefore, we could not be assured people were safe from the risk of choking. Information to support staff to safely give ‘when required’ medicines was not always in place or fully completed. There was a risk that people might not have got their medicines when they needed them.

Medicines audits were not always effective in identifying medicines related issues occurring in the service. Proposed actions from these audits were not always completed. For example, records for medicated patch application were meant to have been put in place but this had not been done at the time of assessment. The manager was unable to explain why there was a delay in completing the required actions, and the oversight of medicines within the service was not always effective. We were not always assured that medicines incidents were recorded, analysed and learnt from. Therefore, we could not be assured that a good safety culture was in place. Staff members told us that risk assessments were not in place to prevent inappropriate access to creams stored in people’s rooms.

Effective processes were not in place for the management of controlled drugs. Records of controlled drugs were not always accurate and were not in line with legislation, best practice and the provider’s own policy. We were not assured from discussion with the manager that incidents were always recorded. An effective medicines reconciliation process was not in place to ensure people’s current medicines were listed accurately. Because of this, people did not always have a complete and accurate list of their current medicines. Medicines stock counts were not always accurate and were not checked as frequently as the provider’s policy stated they should be. Therefore, we were not assured that people were being given their medicines as prescribed. Records to show when topical preparations such as creams were being applied were not always completed accurately, so we could not be assured they were being applied safely. We found the site of the application of topical patches was not recorded. Therefore, we were not assured the patch site was rotated in accordance with the manufacturer’s instructions. This meant people were at risk of skin irritation.