Park Lane House

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

Care plans and risk assessments in place were difficult to follow and required looking back through reviews to gather the most up to date information and guidelines on how to support people. Medication systems and processes needing improving to ensure medication was being stored, administered and disposed of in a safe way following NICE guidelines, policies and procedures. Recruitment checks did not assure us staff were satisfactory checked to ensure they were suitable to care for vulnerable adults. Reportable incidents were not found to reported by the registered manger to safeguarding or the care quality commission.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they were involved in their care plan and where appropriate relatives were involved in identifying their care needs. Care plans were regularly reviewed with people to ensure the information was up to date and relevant to the person’s needs. People told us, if they were not happy about any aspect of their care, they would speak to staff or the registered manager. Whilst people told us they felt involved in their care, records were not always in place to evidence where reviews or decisions were completed.

The provider was active in responding to concerns raised around the service provided and the management of the home. We saw the provider had held meetings with staff, and this was a safe place for staff to express any concerns they had. Action plans were created, and staff felt listened to.

A system was in place to record any accident or incidents. However, this system was not found to be completed by staff following the provider’s policies and procedures. We found 1 incident of choking not recorded on an accident or incident form. Thismeant there was increased risk that the process of assessing lessons learnt and how to prevent future incidents would be missed. We were not assured a full oversight of accident and incidents was embedded in the home. The provider had regular team meetings with the staff to raise concerns about the service or when they had received a complaint about aspects of the service. This was documented and we observed all staff were aware of the content of the meetings and felt the meetings were useful.

Relatives told us they were involved in the assessment process where staff at the service worked with them to identify their care needs. Not all people told us they were involved in reviews. One relative told us, “A review has not yet happened, but they keep in contact and tell me everything that’s going on.” People we spoke with told us they couldn’t remember a care plan review, however, they were all aware they had a care plan in place.

The registered manager told us how they assessed people referred to the service. For example, where a person was discharged from hospital, a pre assessment was completed with the person before the service started providing care. Where a person was referred to the service by the local authority, the process was the same, however, the registered manager would also set up visits to the service and visit the person in their current care setting. Guidelines on how to care for the person were created and put into place prior to staff providing care. Staff felt when a new person moved into the service they were fully involved in the assessment and knew the person’s needs. Partners and stakeholders had identified improvement was required with care plans. We saw an action plan where this had been an ongoing concern since 2021. We raised this concern with the registered manager, who told us they had taken action to ensure the most up to date information was at the front of the paper care plans, and they had funding now secured for the implementation of electronic care records. No date could be provided for when this would be present in the service at the time of this assessment. Partners did not raise any concerns with how people were assessed or moved into the service.

Systems and processes were in place to ensure assessments were completed prior to people using the service. However, we did find where assessments took place this did not always include the assessment of people’s mental capacity. This meant, where people were seen to lack capacity, there was no formal documentation to evidence how this had been assessed or the appropriate people involved. We found a review process was in place to ensure people’s needs were correct. Whilst reviews took place, it wasdifficult to find the most up to date care plan information in care plans, as reviews were recorded on the care plan guidelines section, meaning the most up to date agreed care was at the back of the records.

Everyone we spoke with told us they felt safe and had no concerns about their safety. One relative told us, “Mum is more than happy. She enjoys the food, and the staff are always asking if she wants a drink. The staff interact with her”. One relative did provide feedback of concern, as they told us, “They don’t speak to you. They only want your money”.

The registered manager and staff understood people’s mental capacity. Staff told us they had completed safeguarding and mental capacity training. Staff told us how if they felt any concern was present with a person’s wellbeing or mental health they would raise this with the registered manager. Staff were also aware of the process to report externally to the local safeguarding team or care quality commission. Staff told us they felt where safeguarding or any concerns were reported, these would be listened to and the registered manager and provider would respond appropriately.

We observed people treated with respect and dignity. Staff knew people well and cared for them meeting their needs.

No system or process was in place to assess people’s mental capacity. Where decisions were made around people’s capacity no best interest record was in place to record who was involved and how the decision was made. Whilst staff and the registered manager were aware of who had mental capacity and who didn’t, care plans did not provide detail of the assessment, but did record whether the person had capacity or not. The provider had a safeguarding policy in place, we did find reportable incidents that are reportable to safeguarding and the care quality commission, however, the registered manager had failed to submit notifications in the agreed timescale following policy and procedure.

People and relatives told us they were involved in their care plans and risk assessments. People and relatives told us people felt safe and the service responded to risks.

The management team told us how they involved people, relatives and appropriate stakeholders in identifying and assessing personal risks. Staff told us they understood the management of risks. However, we observed risks were not always monitored or managed effectively to keep people safe. The registered manager took our feedback positively and identified the improvements needed to ensure records were updated quickly and risks were recorded appropriately in people’s care records.

Whilst most risks were identified for each person, reviews of people’s care plans and guidance was not updated to mitigate new risks that had become present to people. Care plans did not easily identify the most up to date guidance following a reviews of incidents. For example, where a person had experienced a choking incident resulting in a change of needs, this was not reflected in their care plan. Where people had identified pressure areas this was not always effectively monitored. For example, where a person was permanently in bed, we found reposition charts were not completed regularly to evidence where a person had been repositioned. This meant people were at increased risk of harm.

People told us they enjoyed living at the home. Some people told us they felt the home environment could be improved. However, people told us the environment had recently improved and they were aware of decoration happening.

We saw evidence the registered manager wanted to make improvements to the home and make the home a nicer experience for people. The provider told us they were committed to improving the home, and with the registered manager they believed the improvements needed would be achieved. We observed staff respected people’s property.

We observed on our assessment visit the home had a urine odour throughout. Some carpets were worn and threading. Commodes in people’s personal bathrooms were not kept clean. We saw wires in people’s bedrooms were hanging out of the call bell systems. Where people had a diagnosis of dementia and lacked mental capacity, no consideration has been given to these risks. We observed in several people’s bedrooms furniture was collapsing and broken. Walls were scuffed and in need of re-decoration.

The provider told us they completed weekly visits to the home and when present they completed a walkaround. This had allowed them to identify improvements needed. The registered manager evidenced they had raised concerns with the home’s appearance and with the provider had come up with an improvement plan. On the improvement plan this had issues identified, for example, carpets being worn. However, the plan did not outline dates for these actions to be completed. We saw no evidence any auditing took place to look at the environment, or the frequency this was to be completed.

People and relatives told us they saw the same consistent staff team and rotas we saw confirmed this. People we spoke with provided positive feedback around staffing. 1 person told us, ‘I love the staff here, they are like family’. 1 relative told us, ‘The staff are wonderful, very friendly’.

Staff we spoke with told us there were enough staff to support people appropriately. The registered manager told us they were actively recruiting. This was due to the home having vacancies and potential new people moving in at any time. During this assessment visit, the registered manager told us they had enough staff to safely cover people’s care needs.

The provider had a recruitment process in place. However, we found this process was not robust in ensuring all recruitment checks were completed to ensure staff were suitable and safe to work with vulnerable adults. For example, we identified the provider had only sought character references for 1 staff member.. We raised this to the registered manager to identify if there was a reason professional references were not obtained. The registered manager told us there was no reason and this was due to a lack of oversight. Where people had a transferable Disclosure and Barring Service (DBS) check no formal checks were evidenced on the recruitment records to show the provider had completed a check to ensure up to date and correct information was present. Staff completed an induction when they first started. This included shadowing experienced members of the staff team, reading care plans and risk assessments and completing mandatory training. We saw evidence staff received regular supervisions. At the time of this assessment there were enough staff, however, we did raise to the registered manger how staff are deployed around the home. The registered manager told us they would review this.

Staff we spoke with told us they received training in infection prevention control. Staff said they had access to plentiful supplies of the right personal protective equipment (PPE). The provider and staff were aware of current relevant national guidance. One staff member told us, “We have no concerns with PPE, it’s always available”. Staff described how they followed guidance to dispose of PPE. Staff also told us how they followed guidelines to effectively and safely wash their hands to prevent infections.

Areas of the home were not visibly clean and well maintained. We observed some equipment required further cleaning. On a few occasions during our site visit we identified PPE points which should have had gloves and aprons present but were empty and not refilled. The registered manager took on our feedback and told us they would ensure regular checks of PPE stations took place.

The home had guidance and posters to encourage and direct staff to keep good standards of infection control. Staff had access to the infection control policy and procedure and as part of new staff’s inductions we saw evidence staff were directed to read this. Training for staff was provided yearly. The registered manager and provider completed walkarounds of the home which included spot checking staff to ensure they were following good practices and procedures.

People told us they had no concerns with how their medication was managed and administered. 1 person told us, ‘I always have my medication on time’.

The staff we spoke with told us they received training to support people to take their medicines safely and this was refreshed yearly. Staff told us they received training and after this they would be observed by management. The management team told us they ensured all staff received medicines training at induction as well as refresher training regularly.

The provider had policies and procedures in place. This included processes of ensuring staff were trained and medicine was administered safely. Medicine audits were conducted weekly by a senior. However, this was not effective in identifying the concerns we found during our assessment visit. For example, medicines were stored in a room where the temperature was consistently recorded as 24 degrees. This raised a concern as some medicines found should not be stored above 25 degrees. During our assessment visit we completed a spot check and counted the medicines kept within the home. We found a discrepancy in the count completed whereby there was 1 less dose present in comparison to what had been recorded. This was found to be an error whereby a staff member had not signed the medication administration record (MAR). The auditing system in place would not have identified this error in a reasonable timescale. Where people were prescribed patches for pain relief, we found no evidence of a body map in place to record where the patch had been applied. As the patch was to be alternated, this increased the risk of harm to people. Prescribed creams were not locked away and were stored loosely all over the home, which does not meet the requirement set by NICE guidelines. We found prescribed creams did not consistently have dates they had been opened recorded.This meant it was not always easy to identify if a cream was out of date. Body maps were found to be in place but did not have the correct guidelines of where creams should be applied. We raised this during our assessment and the registered manager told us they would review all body maps. ‘As required’ (PRN) guidelines were not in place for all PRN medicines, which meant staff were not clear on the triggers or expected outcome of this medicine. The failure to safely manage medicines was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 12(1) Safe care and treatment.