Archived: Blossoms Care Home Limited

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Inadequate. At this assessment the rating has remained Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safeguarding people from abuse, mitigating risks to people, staffing, and the safe recruitment of staff.

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.

The provider did not have a proactive and positive culture of safety based on openness and honesty. Lessons were not learnt to continually identify and embed good practice.

At our last 2 inspections we found that incidents were not well managed. At this inspection, we continued to identify concerns. The Nominated individual (NI) shared with us an incident log which they told us had all incidents documented. The last incident recorded on the log was dated 13 March 2025. The NI told us that there had been no incidents since this date. However, we identified that there had been numerous incidents including (but not limited to) incidents of distress that occurred on 21 October 2025, and medical incidents, for example when someone had a seizure on 1 October 2025. We shared this concern with the NI and they told us that these incidents had not been reported to them by staff and said of the lack of incident reporting, “It’s a blind spot.”

The NI and provider failed to ensure that all incidents were reported and action taken to address and mitigate risks. During our inspection we observed incidents where staff did not support people in a safe way, either to reduce distress, or when they used poor manual handling techniques.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

At our last inspection, we found that the provider had not maintained safe systems of care. At this inspection, we continued to identify concerns. The provider and NI failed to ensure that care plans were up to date and reflective of people’s needs. They failed to ensure there were systems in place to appropriately document seizures, or incidents of concern which meant these could not be collated and shared with the relevant healthcare professionals. When people lost weight there was no system to identify this, and the provider and NI relied on other health professionals to identify this, and request action be taken.
One person had specific communication methods. The provider had sourced support for this person, which included attending appointments to try to ensure their voice was heard.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

At our last inspection we found that people were not safeguarded from the risk of abuse. At this inspection, we continued to identify concerns. Staff had received training in safeguarding; however they failed to implement this successfully within everyday practice. For example, we observed 2 incidents where 3 staff members were involved in poor manual handling incidents. We identified within daily notes that people had multiple incidents of distress, which had not been identified as potential safeguarding's. We reviewed the providers safeguarding log and found that not all incidents had been recorded. Safeguarding oversight was poor and lacking.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At our last two inspections we found that risks to people were not well managed. At this inspection, we continued to identify concerns. Risks relating to people’s health and wellbeing had not been identified or mitigated. For example, a visiting healthcare professional identified 1 person had lost 10kg of weight in 2 months. Staff had failed to identify this and seek urgent medical attention. We found there was not a system in place to review people’s weights and take action if people gained or lost a concerning amount of weight.

We identified 3 people at the service had epilepsy. This was not known by the NI or the provider. One person’s care plan relating to seizures was poor and did not contain sufficient guidance for staff to follow should the person have a seizure. When people did experience seizures these were not always formally documented to look for patterns and trends or share with healthcare professionals.

Other health risks to people were not well managed, including ensuring people were supported to re-position regularly to ensure their skin did not break down. Some people could become distressed, and we found this was not well supported by staff. We observed staff using poor manual handling techniques which posed significant risks to people.

The provider did not always detect and control potential risks in the care environment.

At our last inspection we found that risks to the environment had not been mitigated. At this inspection, we continued to identify concerns. The environment was not well maintained, was tired and in need of improvement. For example, within one person’s room, where a call bell had been removed, the back plastic casing was exposed, which could cause harm to someone should they fall against it. In people’s bedrooms, and within the service there were unguarded radiators which posed a burns risk.

Some people would need help and assistance to leave the service in the event of an emergency evacuation. Individual personal evacuation plans (PEEP) plans were in place, however the folder at the front door, which would be used by the fire rescue service, did not have the most up to date information. This included 1 person’s bedroom being incorrectly recorded. The NI told us that this person had moved bedrooms at least a month prior to the inspection, and this information had not been updated. This placed people at risk of harm, should an emergency occur with professionals not having access to correct, up to date information.

Other checks, including fire safety checks had not always been completed. Some weekly checks on the environment had not taken place. For example, weekly checks should have been undertaken for fire warning system checks, however this was last completed in September 2025. Weekly checks should have been carried out on fire extinguishers, and these were last carried out in July 2025. Monthly checks should have been carried out on emergency lighting; these were last carried out in August 2025. Yearly gas safety checks should have been carried out in 2025 but had not been carried out. We raised this with the NI and they told us they booked for this to be completed.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not work together well to provide safe care that met people’s individual needs.

At our last 2 inspections, we identified that staff did not have the skills, knowledge and competence to support people safely. At this inspection, we continued to identify concerns. Not all staff supporting people were on the training matrix, and therefore we could not be assured staff had completed training. The NI told us they were unaware 3people living at the service had epilepsy and confirmed that no staff had received training in supporting people with epilepsy. The training matrix also demonstrated staff had not received training in catheter care, despite supporting a person with a catheter. Staff had received training in manual handling; however, we observed 3 staff on 2 occasions use unsafe manual handling techniques including a ‘drag lift.’ This technique puts a dangerous strain on the shoulder of people, inevitably causing discomfort and often injury. On the second occasion the deputy manager was present and had to intervene.

The week before our inspection, 2 people had gone into hospital. The NI told us they made the decision to reduce staffing from 4, to 3. Staff told us there were not enough staff. We observed that there were not sufficient numbers of staff. One staff member administered medicines in the morning, leaving 2 staff members to support 13 people with personal care, and serving their breakfast.

The provider failed to ensure that new staff were recruited following safe practices. There was a wide range of information missing from staff files, including references, right to work checks, start dates and application forms. The provider also failed to ensure that The Disclosure and Barring Service checks (DBS) were completed before staff started working with people. DBS checks helps employers make safer recruitment decisions. For two staff members these checks were only completed the day after our inspection. The provider could not be assured that staff were recruited safely.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service was not clean or well maintained in places to make cleaning effective. Areas including people’s rooms, hallways, communal areas were visibly dirty with stains of fluids down the walls and floors, and marks on carpets. One person’s bedroom had 2 brown stains on a chair, which looked to be faeces. In another person’s room we found discarded, used personal protective equipment (PPE) on one person’s bedside table. The bin in the living area, and in the bathroom on the ground floor had broken lids, meaning they could not be used effectively. There were several areas including handrails, and flooring in bathrooms which were significantly worn, making effective cleaning difficult.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

At our last inspection we found that medicines management was not safe. At this inspection, we continued to identify concerns. We continued to find that that guidance for ‘as and when’ medication was not always in place or sufficiently detailed. For example, when people became distressed, guidance was not clear when to administer medication, and staff did not document why they gave the medication, any de-escalation attempts prior to administering, the dosage of the medication or if it was effective. Some people were being given ‘as and when’ medicines routinely without clear justification. Staff did not understand their responsibility in relation to the management of controlled medicines. Staff were disposing of prescribed pain patches in the general waste bin which is not in line with NICE guidance.

There were no risk assessments in place for paraffin-based creams, which posed a fire risk. There was no risk assessments for people who were prescribed blood thinning medicines, which posed a greater risk to them if they were to fall or injure themselves. Creams and thickeners were not dated when opened which meant staff could not be assured they remained effective. Some people in the service were prescribed topical pain patches. The provider had a process in place to record the application and removal of these patches; however, this was missing for one person’s prescribed medicine and there was no use of body maps to support staff to know where patches were routinely being applied to. This can increase the risk of a person experiencing an adverse effect from repeated applications of patches to a similar site.

We asked the NI and provider to demonstrate that staff had received competency checks in relation to medicines management. They did not provide these. We observed that staff were not competent when administering and discarding medicines.