Archived: Blossoms Care Home Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not ensure the delivery of high-quality care. The service was in breach of legal regulation in relation to governance at the service. There had been little improvement since our previous assessment and the service remained in breach of regulations. A new manager had been employed and was trying to improve the culture and morale at the service, but this had not been well embedded. Some of the concerns we previously identified remained a concern at this inspection and people remained at risk of poor care and unsafe treatment. The provider had not established robust systems of oversight, and we were not assured that leaders had the skills or competence to make the required improvements expected.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Since our last inspection a new manager had been recruited. They told us they had been working with staff to improve the culture and how the team worked together. They said, “Staff been here for a long time, 10 plus years. The culture has been a bit tough to break. I think now the staff have got to know me and I've got to know them. It's been challenging last couple of months but so far im quite happy with how things going and how things have settled.” Some of the staff we spoke with spoke positively about the manager and how they were trying to change the culture and improve the morale of the service. However, further work was needed, we identified poor interactions between staff and people that did not demonstrate a shared direction or positive culture for the people living at the service.

The manager told us they felt supported by the provider, but we found no evidence that the provider had significant oversight or input in the service. The service had a history of not sustaining improvement, so the service people received was not consistently safe or good. we asked the manager about the values and goals of the service, they told us, “Can I be honest 60% staff understand. 60% the passion is there but doing it? They fight what is put in place.”

We were not assured leaders had the skills or knowledge to lead effectively. The service had not sustained any significant improvement, and people did not receive safe care and treatment. We were not assured the new manager was receiving enough support from the provider to ensure significant improvement could be made at the service. The provider told us they would start to conduct audits as the manager had asked this to happen to give them reassurance that the service was running well. Although we raised concerns and issued warning notices at our previous inspection the provider had not implemented a robust system to maintain their own oversight of the quality of the service.

Although the manager had been working with staff to improve the culture there was still work to be done. We asked for certain documents during the inspection. We raised concerns with the manager that a senior staff member was writing these documents as we asked for them instead of being open and transparent that they did not have them in place. The manager agreed and said the staff member was panicking.

We found concerns that people were not always heard or supported to communicate, However, the new manager had been trying to encourage staff to speak up more and feel confident to raise concerns without fear of retribution. The manager told us, “Some staff felt they couldn’t come to me, so I told them to put anonymous notes in a drawer for me.” Staff members said, “Support much better than it was, (new manager) good manager, able to speak to them” and “This is my second manager, we are getting there, takes a little while.”

Staff were more positive about the service since the appointment of the new manager. The manager told us they had been coaching staff but did not want to demoralise them so had been doing this slowly. The manager said they had been trying to get to know each staff member and when they had first taken up position some staff were scared and would not look them in the eye. The manager had identified there had been a ‘huge gap’ between the day and night staff who worked as separate teams which was not good for the culture or morale of the service. The manager felt staff were doing what they wanted rather than what was best for the people at the service, and they were trying to improve this. A staff member we spoke said, “Day verses nights at one point, maybe barrier in cultures (about the staff team).”

Systems to ensure clear responsibilities and roles needed further work to improve. For example, when a person had been admitted to hospital the manager’s records stated measures had been put in place to reduce the risk of this happening again. It had been identified that some senior staff had not organised the team well to maintain oversight of the person’s needs. However, we found no evidence checks of records we had been told had been implemented following this incident were being made by senior staff.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. At our last inspection we identified significant concerns around risk management in relation to management of distressed emotions, falls, choking, restrictive interventions, pressure damage, dehydration, fire risks, staff training and competencies put people at significant risk from inappropriate manual handling techniques being used. We were concerned there were ineffective oversight of the service with ineffective systems and processes which did not effectively assess, monitor and mitigate risks relating to health and safety and welfare of people. This had put people at significant risk of harm. Staff did not have the information required to safely support people.

At this assessment we have found continued concerns in the management of risk and people have been placed at significant harm because the support they receive in relation to their individual health needs was poor. The provider has continued to fail to ensure there was effective oversight to assess monitor and improve the quality and safety of the service. Systems and processes had failed to identify and mitigate risks. This has put people at continued risk of not having their needs met. It had not been identified that care plans and risk assessment lack important information or are inconsistent. Systems to monitor the service were not effective, for example the issues we found with medicines had not been identified through the audits which had been completed. There is a continued failure at the service to provide consistent safe care to people. Any improvement that had been made previously has not been embedded or sustained.

People experienced delays in having their health needs met. Records indicated people had not received sufficient fluid or had not opened their bowels which was not identified by staff or shared urgently with other health care professionals.

Other referrals had been made for example to the speech and language therapist (SALT) when concerns had been identified with people being at risk of choking but robust risk management of this had not been implemented.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local systems. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe and effective practice.

At our last inspection we identified poor management and oversight of the service which had exposed people to the risk of harm. There had been little learning from this, and we found continued risks and concerns. Although the provider had improved the fire safety at the service other areas of risk remained, including the risk of people choking, constipation, dehydration, managing distressed behaviour, falls and wound risk. Any action that had been taken was not effective or embedded.

The manager and provider told us they felt they had made the necessary improvements since out last inspection, but we found this was not the case. There was no well-established oversight of the service, the provider relied on the new manager to make the necessary changes but they had spent much of the time since starting at the service trying to establish a positive rapport with the staff team and making changes to the poor culture.