CQC report explained · a nursing home
What the CQC found at Parklands Court Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2023
Parklands Court Care Home is rated Requires Improvement; inspectors found medicine, staffing and management weaknesses, although infection control had improved.
This was an unannounced focused inspection on 15 August 2023. Inspectors reviewed Safe and Well-led only because of concerns about staffing and poor-quality care. They spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and quality records.
The home was not always safe. Medicine records on one unit did not always show whether people had received their medicines. Some people experienced delays when staff were not available, especially in the evenings. Staff recruitment checks were mostly safe, but previous employers' conduct information was not always obtained.
The home was not well-led. Audits and quality systems had not brought about enough improvement, and the provider remained in breach of Regulation 17. People, relatives and staff said communication was poor. A new management team had started and was developing an improvement plan.
The overall rating remains Requires Improvement. Infection control had improved since the previous inspection, and the earlier breach about infection control was no longer in place. The other three question ratings were carried forward because they were not inspected.
Risk management
Staff understood people's needs and care plans gave guidance about risks such as falls, diabetes and skin damage.
“Risks to people's health, safety and well-being were assessed and managed.” from the report
Infection control
Inspectors found visible improvements in infection prevention. The home was clean and staff followed measures to reduce cross infection.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Safeguarding
Staff knew how to identify and report safety concerns. Records showed that concerns were escalated and referrals were made when needed.
“Staff were aware of how to identify concerns for people's safety and records reflected concerns were escalated so that action could be taken to protect people from harm.” from the report
Consent and choice
Staff sought consent before care and worked within the principles of the Mental Capacity Act.
“Staff sought consent from people before providing care and were aware where people lacked the mental capacity to make specific decisions.” from the report
Medicine records
seriousOn one unit, stock records did not match medicine administration records. Staff could not always confirm that medicines had been given as prescribed.
“On Collins unit records of medicines in stock did not always match the Medicines Administration Records (MAR).” from the report
Staff availability
needs fixingSome people reported long waits for staff, including in the evening. Inspectors asked the management team to review staffing allocations.
“If I press my buzzer, I sometimes have to wait quite a long time.” from the report
Weak quality oversight
seriousAudits and governance systems had not driven enough improvement. They did not always identify or follow up safety issues, including medicine concerns.
“The provider had failed to establish systems to effectively assess, monitor and improve the quality and safety of the service.” from the report
Communication
needs fixingPeople, relatives and staff did not always feel involved or supported. Staff described supervision as inconsistent and communication about changes as poor.
“People and their relatives told us they did not feel involved in the changes being made at the home.” from the report
- 01How do you now check that medicine stock records match the administration records on every unit?
- 02What has changed to reduce delays when people use their call bells, particularly after 7pm?
- 03How are lessons from incidents and medicine audits shared with all relevant staff?
- 04Who is responsible for checking that missed audit actions are completed and that safety issues are followed up?
- 05How will people and relatives be kept informed and involved in the changes planned by the new management team?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 10 October 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2023
Requires Improvement; inspectors found risks in infection control, management checks, mealtimes, dignity and activities.
This was an unannounced inspection on 29 and 30 September 2022. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicines records, recruitment files and management records.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from abuse and had care plans, risk assessments and medicines arrangements in place. Staff usually knew people well, offered choices and supported communication and end of life care.
However, infection control was not good enough. Some areas and equipment were dirty or damaged, recruitment checks had gaps, and not all nurses had up-to-date medicines competency checks. Mealtimes were disorganised, some personal care and dignity needs were missed, and there were too few activities. The provider remained in breach of regulations about safe care and treatment and good governance.
Protection from abuse
People and relatives said they felt safe. Staff understood what to do if they had concerns, and safeguarding incidents were investigated.
“People were protected from the risk of abuse.” from the report
Care planning
Care plans and risk assessments gave staff guidance about people's needs and how to support them safely.
“People had person centred care plans and risk assessments which provided guidance for staff to follow to support them safely.” from the report
Choices and consent
People were offered choices, and staff sought consent before carrying out care. The report found that the home was working within the principles of the Mental Capacity Act.
“We observed staff offering people choices.” from the report
End of life support
People had end of life plans that included their wishes and, where needed, relatives' involvement. Staff had received end of life training.
“People received end of life care in line with best practice.” from the report
Infection control
seriousInspectors found dirty areas, damaged surfaces and unclean or damaged equipment. This created a risk that infection control would not protect people.
“The provider had not ensured people were protected from the risk of infections through their infection control practices.” from the report
Mealtime support
needs fixingSome people waited over 30 minutes for food, and some people eating in their rooms did not receive enough support. Some food went cold.
“The mealtime experience was disorganised.” from the report
Dignity and personal care
needs fixingSome people were not helped to change clothes after food spillages. Inspectors also saw one person's continence pad hanging down and clearly visible.
“Staff did not always respect people's dignity needs.” from the report
Activities
minorInspectors saw very few activities. People were sometimes sitting without stimulation or sleeping, and staff said they did not have time to talk with people.
“We observed very few activities taking place.” from the report
Medicines competency checks
needs fixingOnly 9 of 19 registered nurses had completed competency checks, and 7 checks were out of date. Inspectors said this increased the risk of medicines not being given as prescribed.
“This put people at increased risk of not receiving their medicines as prescribed.” from the report
- 01What has been done to clean and repair the areas and equipment identified as infection risks?
- 02How many nurses and other staff currently have up-to-date medicines competency checks?
- 03How are mealtimes now organised, especially for people who eat in their rooms or need help to eat?
- 04What checks now make sure personal care, clothing changes and continence care protect people's dignity?
- 05How many activities coordinators are now in post, and what regular activities are available for each unit?
This was an unannounced inspection covering all five key questions, including the premises and care provided; it was prompted partly by concerns about nutrition, hydration, personal care, staff conduct, neglect and management. This explanation was written from the published report of 6 January 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Parklands Court Care Home
6 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2017
Registered with the Care Quality Commission on 30 November 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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