Archived: Park Lodge

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

The provider had not taken enough action to meet a breach in legal requirements we found at our last inspection (published in December 2022). They were continuing to place restrictions on people’s liberty without the necessary legal authorisation to do so. Staff did not have access to relevant information to help them safeguard people from abuse. The provider continued to be in breach of regulation 13 of the HSCA 2008 (Regulated Activities) Regulations 2014. We found concerns about the safety of the premises, equipment, fixtures and fittings because they had not been properly maintained or suitable for the use they were intended. This resulted in a breach of regulation 15 of the HSCA 2008 (Regulated Activities) Regulations 2014. We found concerns around staffing at the service. There were not enough staff on duty to meet people’s needs. Staff had not been provided with the training and supervision they required to undertake their roles, which resulted in a breach of regulation 18 of the HSCA 2008 (Regulated Activities) Regulations 2014. We found concerns around recruitment and insufficient checks on staff’s suitability to support people, which resulted in a breach of regulation 19 of the HSCA 2008 (Regulated Activities) Regulations 2014. We found concerns around the safety of food storage which resulted in a breach of regulation 12 of the HSCA 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. Notwithstanding the concerns we found above, people felt safe at the service. People were involved in managing risks and taking decisions about how to keep safe. Staff were provided with information about how to manage identified risk to people and understood how to reduce safety risks. The service was clean and tidy and people and visitors were supported to minimise infection risks.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff knew people well and understood how to recognise abuse and to report any concerns they had to the manager. A staff member told us, “I know what abuse is and if I see anything that looks like that, I would speak to the manager.” Staff were encouraged to speak up if they thought something was wrong. A staff member told us, “We can say what we think. I do have a responsibility to speak up if something wasn’t right.”

People did not live in fear of abuse or harm at the service. People told us they felt safe at the service and liked the staff team that supported them. People said they could talk to staff if they were angry or upset and felt they would be listened to.

People were comfortable and at ease with each other and with the staff team supporting them. There was a relaxed family style atmosphere at the service. Interactions between people and staff were cheerful and friendly. Staff made sure everyone could speak if they wished to and that people respected each other in conversations. Staff showed genuine care and concern for people and their wellbeing and acted quickly to reassure and comfort people when they needed this.

At our last inspection of the service we found the provider was placing unlawful restrictions on people’s liberty. The provider was continuing to unlawfully deprive people of their liberty. We reviewed 4 people’s care records which detailed these people lacked mental capacity to make specific decisions and needed close supervision when being supported by staff. However, the provider had not submitted the necessary Deprivation of Liberty Safeguards (DoLS) applications and therefore were placing unlawful restrictions on their liberty. Staff did not have access to relevant information about their duties and responsibilities to safeguard people from abuse. The provider could not provide us with a current safeguarding policy and procedure for the service. Their safeguarding folder contained out of date guidance which did not reflect current practice. This meant people were at increased risk of not being protected from abuse because staff did not have the relevant information to help them take the right action to safeguard people.

People’s care records contained current information about identified risks to their safety. This meant staff had up to date information about the action they should take to manage these risks and keep people safe.

People were involved in managing risks to themselves and in taking decisions about how to keep safe. One person told us they regularly travelled independently in the community to visit with friends and family. They had been involved by staff in discussions about how any risk to them would be managed to help keep them safe when travelling alone.

People were supported to do the things they wanted to do and staff helped them to do this safely. One person needed support from staff to help them move around the service. We saw when they wanted to leave the communal lounge and go to their bedroom, staff made sure they did so, safely. Staff were patient and made sure the person understood they did not have to rush and could move at their own pace.

Staff understood risks posed to people and the action they should take to reduce these, so that people could do the things that mattered to them. A staff member told us, “There should be risk assessments in place for people. People can take risks and make risky decisions so you have to respect this as long as you educate people as to what the risk is.”

Staff understood how the environment might pose risks to people and how they could support people to stay safe at the service. Staff told us they reported any safety concerns about the environment to the provider. However, staff said the provider did not always act promptly to address these concerns.

The provider had not made sure the environment was always safe for people, through regular checks and to prompt management of risk when concerns were identified. The provider’s records showed only minimal checks had been made within the last 12 months and these were limited to servicing and maintenance of the gas boiler, the fire system and equipment, water hygiene and hot water temperatures from outlets. The provider could not show us evidence during our site visit that portable electrical appliances had been tested within the last 12 months by a qualified person. This meant they had no assurance these continued to be safe for use. After our site visits, the provider sent us evidence that a safety test of all portable electrical appliances had been completed. The issues we found during our assessment demonstrated the provider’s current arrangements for identifying safety concerns were limited and ineffective in scope. Although the provider took action to address some of the issues we found, we were concerned the provider did not have effective systems in place to identify and act sooner to reduce risk to people.

We spent time with people to learn more about their experiences of using the service. People’s feedback did not highlight any concerns they had about the safety of the environment.

The environment was not always safe for people. There was mould present in 2 bathrooms. The presence of mould increased the risk of harm to people from respiratory problems, allergies or asthma. One of the shower cubicles had a broken door which increased the risk of people getting caught and injured by it. In a person’s bedroom we found trailing wires from a wall mounted television, resting against an exposed hot radiator below it, which was a fire safety risk. The settee in the communal lounge was torn in 2 places and the blind in the conservatory was broken and had missing slats which made these items unsuitable for use. After our site visits, the provider sent us evidence of action they had taken to address some of the concerns we found and mitigate safety risks to people. They had purchased and installed 2 new settees for people to use. The broken blind had been replaced. The exposed radiator had been covered and the trailing television wires had been safely secured. Although the provider had taken action to address some of the safety concerns posed by the environment, some concerns still remained and continued to pose a risk to people’s safety.

Staff were not being supported to provide safe care to people that met their individual needs. A staff member told us, “We are at least 3 staff down. 2 people need 2 staff for personal care. Quite a few staff have left. [The provider] says they’re recruiting but I don’t know for sure. You really notice the lack of staff when you are trying to do paperwork and you can’t give people your full attention. We are also having to do the cleaning which means less time with people.” Another staff member told us, “I would like to do more training in this job. I am not getting the training I want.” One of the 2 partners managing the service acknowledged there were not enough staff to support people. They told us they were actively recruiting at the time of our inspection for more staff. The partner told us they did not attend the service every day but was contactable by phone if staff needed additional support.

During our first site visit, there was only 1 staff member on duty when we arrived at the service. They were supporting 7 people. We were told there should be 2 staff on duty but the second staff member had left to undertake a personal errand. They arrived back at the service 20 minutes after our arrival. This meant during the time they were away from the service there were not enough staff available to ensure people remained safe and their individual needs could be met. One of the 2 partners managing the service was present during our site visits. They were not scheduled to be at the service but came to provide support to the staff team after our arrival. The presence of the partner at the service meant staff were able to provide care and support to individual people and not leave others without access to support if they needed this.

There were not enough staff deployed to meet the needs of people using the service. Staff rotas showed 2 staff were on duty during the day and at night. Our review of people’s care records showed some people required the support of 2 staff with aspects of their care. This meant when these people were being supported by staff, other people at the service were left unsupervised and without access to appropriate support from staff to meet their needs. The provider had no arrangements in place to review staffing levels to make sure there were always enough staff to safely meet people’s needs. Staff did not receive all the training needed to meet people’s needs. Records showed staff had not completed all the training courses relevant to their role. This meant people were at risk of not having their needs met by staff that were sufficiently skilled and experienced to meet them. Staff were not being supported to learn and develop in their role. Records showed staff had not received recent formal supervision. In the absence of regular supervision, the provider could not be assured staff remained competent and supported to carry out their duties. The provider was not operating safe recruitment practices. Records showed the provider had not taken up references for 2 staff prior to them working at the service. Additionally, the provider had not undertaken a right to work check for 1 staff member so had not made sure they could legally work at the service. These issues increased the risk of people receiving unsafe or inappropriate care from potentially unsuitable staff.

People had mixed views about staffing at the service. People gave us positive feedback about staff and did not indicate they had concerns about them. However we also received feedback which indicated there were not enough staff to support people. A relative told us, “It feels disorganised. I don’t know if they have enough staff. But I think [family member] is fine here.”

We spent time with people to learn more about their experiences of using the service. People’s feedback did not highlight any concerns they had about cleanliness and hygiene at the service and staff’s practice to minimise the risk of infection.

Staff had been provided with training and support to help them minimise infection risks at the service. A staff member told us, “We’ve done training in infection prevention and control and we have personal protective equipment (PPE) if we need it. There are enough cleaning materials.”

Staff did not always follow current practice to minimise infection risks. We found meat stored in 2 separate freezers that had been taken out of its original packaging and put in freezer bags. There were no labels on the bags to specify when these had been opened and when the meat should be used by. Staff had no way of knowing if the meat was safe to use, which put people at risk of infection from potentially out of date meat. One of the fridges was emitting an offensive odour but the source of this could not be established. After our site visit, the provider sent us evidence the fridge had been removed and a new fridge freezer had been purchased and installed. Notwithstanding the concerns above, staff followed current practice when supporting people and used personal protective equipment (PPE) when this was required. The service was clean and tidy and there was appropriate signage and supplies to help people and visitors minimise infection risks.

The service had infection prevention and control (IPC) measures in place to keep people safe. The service’s IPC policy was up to date so staff had access to current guidance to support them with their practice. The service knew how to respond to risks and signs of infection and how to make sure infection outbreaks at the service would be effectively prevented or managed. There were arrangements in place to make sure the environment was cleaned by staff at regular intervals.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.