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 requires improvement. At this assessment the rating has changed to 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 people’s safe care and treatment, safeguarding and safe and effective staffing. People were not protected from the risk of harm; staff did not have adequate guidance or risk assessments to refer to when supporting people. We were not assured staff had the skills or competence to meet the individual needs of people. People were not well safeguarded, some people had particular communication barriers which meant they were exposed to further risk, and this had not been well considered or supported. Medicines were not managed safely; the oversight of this was also not safe.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our last assessment we identified significant concerns with the safe care and treatment of people. People were left at risk of harm due to ineffective risk mitigation and oversight. At this assessment we found continued concerns around risk management and people continued to receive care in an unsafe way. There had been no learning since our last assessment and the service had a poor history of sustaining quality care to ensure people received safe care and treatment. The provider did not have any oversight of the service, although they said they would be establishing this. Professional partners fed back to us they had been supporting the service but was not confident any improvement would be made or sustained.

The provider did not establish and maintain safe systems of care. They did not assess, manage or monitor people’s safety effectively. People’s needs were not assessed in a holistic manner and care plans for newly admitted people lacked important information or risk mitigation. For example, a person had moved into the service in December 2024. Their care plan contained no information about their specific health needs or how staff should support them, some staff had a poor knowledge about the person’s needs.

People were not safeguarded from inappropriate care and treatment. Staff had poor guidance and understanding of how to support people with distressed behaviours. One person could become frustrated when unable to communicate their needs. Their care plan lacked any specific guidance or risk assessment about how staff should support them when they became distressed. We observed the person trying to engage with staff with gestures and body language. Staff either did not respond or provided very limited interaction with the person ignoring their attempts to communicate. The person was prescribed as and when medicines (PRN) due to their distressed behaviours but there was no protocol or guidance to inform staff at what times or when it would be appropriate to administer these medicines. There was no robust oversight or monitoring to assess if PRN medicine was administered appropriately or if it had the desired outcome. People were not safeguarded when incidents occurred. Although the manager and provider had made safeguarding referrals when incidents occurred, learning from incidents was not effective. For example, a person had been admitted to hospital in September 2024 due to severe dehydration and constipation. Although the manager said ‘lessons had been learned’ we continued to find significant concerns around the management of people’s fluid intake and constipation management during our assessment, which meant people were at risk of continued harm. A person could display sexualised behaviours towards staff. We asked to view the risk assessment around this, but this was not shown to us. We were not assured staff had the skills or guidance to respond to any incidents of sexualised behaviour which put them at risk. Following the inspection, the provider implemented a risk assessment regarding sexualised behaviours. However, this was inadequate and did not mitigate the risk and keep people safe.

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 and supportive. At our last inspection we identified risks in relation to distressed behaviours, falls, choking, restrictive intervention, pressure wound damage, dehydration, fire risks, and inappropriate moving and handling. At this inspection we found some areas continued to be of concern and other risks had not been mitigated. For example, some people were at risk of dehydration. There was not always information about how much people should aim to drink and there was no robust oversight to monitor the amounts of fluid people drank daily. Where records showed people had not reached their target fluid there was no further follow up or action taken in response.

One person had been identified as ‘at high risk of falls’ in the information the local authority had provided the service. The manager told us they had not identified any concerns with the person’s mobility. However, we observed the person struggling to walk and they were shuffling their feet. Two staff members had to support them whilst they walked to ensure they did not fall. The information in the person’s care plan, which was not dated about how they should be safely supported to mobilise was not robust or a reflection of their needs.

Some people were at risk of choking. Guidance around managing choking risks was not detailed or robust. There was no information about what staff should do should a person choke. The provider sent us further information about managing choking risks after our onsite inspection. However, we were not assured guidance was robust or the staff had the skills to be able to deal with any choking incidents safely.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment and facilities supported the delivery of safe care. Some people were being cared for in bed and had pressure relieving mattresses. One person’s mattress needed to be set according to the person’s body weight to minimise the risk of skin breakdown and pressure wounds. The manager told us they did not have suitable equipment to weigh these people. The provider told us they would be purchasing the necessary equipment following our feedback about this. Records around water temperature testing did not provide assurance that temperatures were safe. It was not clear if all taps, including unoccupied bedrooms were regularly tested. The manager said 3 new people would be moving into the service shortly. The records for the last 3 months of checks were all identical, the manager agreed this was not usual for the temperatures to all be the same. We were not assured accurate temperature checks were being completed. Parts of the environment needed updating and repair to ensure infection prevention control would be effective. There was a rusty toilet frame in a downstairs toilet which would be difficult to clean effectively. The flooring outside of the office was in need of repair and was uneven to walk across and a trip hazard. Disinfectant and cleaning products had been left out unattended on a trolley, there was no associated risk assessment about this, and the manager said this should have been locked away. Some people had sensor mats in their bedrooms. Edges of the sensor mats could cause a trip hazard as they were in need of repair or replacement.

The provider did not make sure there were enough qualified, skilled and experienced staff. At our last inspection we identified staff did not have sufficient skills to support people. At this inspection we found staff continued to lack the training and support required to support people with their individual needs. The updated training matrix detailed only 2 staff have completed the falls awareness training, both dated 25 January 2025 (after our onsite inspection). We found poor practice around medicine administration and staff had not taken appropriate action in response. Some staff had a poor understanding of people’s needs, a staff member told us, “Don’t think anyone at risk of UTI” [Urinary Tract Infection] although several people were at risk of this. We asked another staff member if anyone had issues with constipation and they said nobody was at risk although several people were.

Supervisions records provided no assurance these were regular. Monthly spot checks were carried out by the manager, and they would observe any areas for improvement such as how staff spoke to people. We were not assured the spot checks robustly managed staff. We observed people being spoken to and about by staff in an undignified and inappropriate way. We have no assurance that the manager or senior staff had the skills or knowledge to assess the competency of the other staff members.

Although we observed staff supporting people with their needs some staff commented to us that up until recently staffing had been affected due to one person’s needs who had now moved. A staff member said, “Now (person) not here residents are safe, better atmosphere. Have enough staff.”

Staff were recruited safely. The provider requested references from previous employment and completed other checks on the suitability of staff.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not make sure medicines and treatments were safe and met people’s needs. Medicines were poorly managed and audited. Staff told us 1 person was prescribed ‘when requires’ (PRN) medicines for the management of behaviours due to incidents of distress. There was no PRN guidance, and this medicine was administered and signed as given by staff twice a day regularly from 07 January 2025 to 20 January 2025. It was not clear why staff were regularly administering this PRN. The person was also prescribed another PRN for the management of behaviours due to incidents of distress between 16 January and 12 February 2025 which was administered once on 17 January 2025 at 20:00. There was no PRN protocol or guidance for staff to instruct them when this medicine, which had a sedative effect should be administered. The person had a history of falls identified in their care plan. Medicines with sedative effects are known to increase risk of falls. This put the person risk of avoidable harm and being unnecessarily sedated via chemical restraint without appropriate support, safeguarding and monitoring measures in place. We found poor recording around medicines. The controlled drugs (CD) register records did not reflect the actual stock of medicines present in the controlled drugs box accurately. We discussed this with the manager and established the actual stock of medicines was correct by comparing each items’ records to other records within the medicines return book and people’s records. However, the discrepancies in records were not identified and escalated by staff before our inspection or within the medicine’s audits completed by the manager in October, November or December 2024 where CD records were scored as ‘compliant’. This posed a risk of misuse of controlled drugs going undetected or medicines errors not being spotted and acted upon which put people at risk of avoidable harm. The provider informed us after the inspection these concerns had been addressed.