This unannounced inspection took place on 15 May 2018 with a return announced visit on 17 May 2018. There has been a change of ownership and this will be Parklands Court Care Home’s first inspection since it was registered under the new provider, Advinia Care Homes Limited, in November 2017.

Parklands Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection.

Parklands Court is purpose built and consists of six separate, single storey buildings: Collins, Samuel, Harrison, Marlborough, Elmore and Clarendon. The Clarendon unit was closed at the time our visit. The service is registered to accommodate up to 163 people providing nursing care to older people living with dementia and people who require rehabilitation and palliative care. At the time of our inspection there were 104 people using the service. Parklands Court is currently subject to a restriction on admissions imposed by the local authority and clinical commissioning group. This was imposed prior the registration of the new provider but has remained in place.

The home manager was not yet registered with CQC but told us it was their intention to apply. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

It was recognised the service is undergoing a major transformation. The governance systems had only just started to be implemented and had not been consistently effective at ensuring good working practices were constant across all the units. They were not always effective in ensuring all people received a good quality of service. The manager had worked closely with partner agencies to monitor and improve the quality of the service and where shortfalls had been identified, they were investigated thoroughly and appropriate action plans put into place to reduce risk of reoccurrences. People who used the service, most relatives and staff were confident in the new leadership of the service.

Full information about CQC's regulatory response to issues and concerns found during inspections are added to this report after any representations and appeals have been concluded.

Risks to people had been assessed and processes were in place to reduce the risk of avoidable harm. However, staff members’ working practices were not consistent across the service because we saw unsafe techniques were used to move people. Where risks were identified, we found that staff members were not always provided with the relevant information in people’s risk assessments to keep people safe. Risks associated with peoples’ nutrition were not always managed effectively. People told us they received their medicines appropriately, but some people did not receive timely pain relief because the staff had not identified that people were in discomfort.

People told us they felt safe and staff understood their responsibility to raise concerns regarding potential abuse. There were processes in place to ensure the premises and equipment was checked to maintain people’s safety. People were protected from the risk of infection. There were systems in place to investigate incidents and share learning when things went wrong.

There were not consistently sufficient numbers of staff employed to meet people's needs across the service. Employment checks had been undertaken on staff to ensure they were suitable for their roles. Staff received limited supervision and appraisals, but told us they felt supported by the management team to carry out their roles. Staff members were aware of the provider's policies to pre