Bloomfield Court

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.

This is the first assessment for the service under this provider. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 63 (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 always investigate safety events to identify lessons.

Although accidents and incidents were recorded by staff, and included, where applicable, the external healthcare professionals events were being reported to, the provider did not always analyse safety events for understanding and learning. For example, the ‘management sign-off’ section of incidents and accident records was often blank or contained no information to demonstrate managers were analysing the causes and circumstances of how safety events might have occurred. Although systems were in place for managers to audit accidents and incidents, records showed while these captured summary information relating to events and actions taken, there was limited evidence that the causes and circumstances around events was being analysed to identify learning and mitigate future risks. This meant people were at risk of safety events not being appropriately managed.

However, there were areas of the service in which a learning culture was evident. For example, the way leaders reviewed complaints and audit action plans being used to develop continuous improvements.

The provider did not always ensure safe systems of care.

Effective systems were not in place to ensure safety events were analysed for learning and, as reported elsewhere under safe, that care plans contained relevant information regarding people’s needs and staff always received training relevant to people’s needs. This meant people were at risk of their needs not always being clearly documented, used for learning and understood by suitably trained staff.

However, the service used clear systems in other areas. For example, the provider ensured safe systems of care in relation to the transition process for people before they moved to the service. Leaders told us this process consisted of obtaining information about people’s needs by completing assessments of people with the participation, where possible, of friends and family who know the person well. When we spoke with people and their relatives we were not informed of any concerns regarding this process, with 1 relative telling us, “I was involved in the care planning for my loved one and we review whenever there is a change”.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People informed us they felt safe at the service. One person told us, "I feel very safe with the staff”. Relatives also told us this, with 1 saying, “I feel that my loved one is safe”.

There was a safeguarding policy in place, records showed staff had completed safeguarding training and staff were able to tell us the action they would take if they had concerns. Leaders also told us how safeguarding concerns would be reported to the local authority and CQC, and we saw information in care records which demonstrated this.

The service ensured people’s mental capacity was assessed relating to aspects of their care and people were supported to make decisions for themselves.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service and found people had up-to-date DoLS authorisations in place.

The provider did not always work well with people to ensure their needs and risks were clearly understood.

Care plans and risk assessments did not always contain relevant information about people’s care and health needs. When this information was documented, it was not always clear, person-centred and consistent. For example, care plans which stated people had health conditions did not always provide information detailing how these conditions affected the person nor the support they needed from staff as a result. We found care plans relating to people’s emotional needs did not always specify how they presented when distressed or anxious, or what support staff provide. Care plans and risk assessments relating to people’s health needs sometimes contained generic information and was not person-centred to their individual needs. Some people’s care plans and risk assessments contained contradictory information in relation to their eating and drinking needs, their mobility needs and the frequency they needed to be monitored by staff during the night. This meant people were at risk of their needs not always being met as staff did not have clear guidance.

However, there were examples of care plans and risk assessments containing clear, detailed and person-centred information. Furthermore, staff and leaders demonstrated good awareness of people’s needs and involved people in understanding and managing their own risks when we spoke with them.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was clean and well-maintained. Arrangements were in place to monitor the safety and upkeep of the premises, which included the undertaking of environmental and equipment checks.

The atmosphere and appearance of the home was homely, and people appeared comfortable and relaxed in their surroundings.

However, there were doors to rooms which contained items that could have exposed people to harm should they have been accessed which were not locked, and rooms with signage stating they needed to be locked that also had not been appropriately secured. When this was discussed with leaders, prompt action was taken to address the situation.

The provider did not always make sure there were enough skilled staff.

People were not always supported by appropriately trained staff. The staff training matrix showed staff had not received training in health conditions that were relevant to people’s individual needs. For example, although a person had a diagnosis of epilepsy, staff had not received awareness training in this area, with staff also telling us this was the case. Despite some people having a catheter and receiving catheter care from staff, there were staff that had not received catheter training. Likewise, while some people had diabetes, the vast majority of staff had not received diabetes training, with staff also telling us this was the case. We also found not all staff had received falls awareness, skin integrity and palliative care training, all of which was relevant to people’s needs.

When we visited the service, we observed people being monitored and supported by a member of staff not assigned to carry out personal care duties [KS1]. When we reviewed this staff member’s training records we saw they had not received training in essential areas such as falls awareness, emergency first aid, food safety and distressed communications. When this was discussed with leaders, they acknowledged this was the case and informed us they would address the situation.

This meant people were at risk of their needs not always being understood and met by untrained staff.

However, the recruitment records we viewed demonstrated that safe and robust recruitment practices were being carried out, and staff rotas evidenced staffing levels were consistent and in accordance with the service’s dependency assessment tool.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We found the service clean and tidy, and staff wore appropriate protective personal equipment (PPE) when supporting people to help protect them from avoidable infections. Staff completed infection prevention and control training and confirmed they had access to PPE.

People and relatives told us they were happy with standards in the service, with 1 person saying, “It is very clean here. The staff clean every single day; my bedroom is very nice and tidy." While a relative said, “They make sure the home is clean and tidy.”

Leaders informed us of the systems in place to ensure the risks of infection is minimised. This included the provision of multiple PPE stations within the home, checks and audits of infection prevention and control areas and open communication with both staff and external partners.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff received training in safe medicines management and the staff we spoke with demonstrated good awareness of medicines processes and people’s individual medicine needs.

Clear systems and processes were in place regarding the storage, administration and documentation of people’s medicines, and we observed medicine stock counts were accurate which indicated people were being supported to take their medicines as prescribed.

Leaders told us how they used an electronic medicine system to monitor medicine practices, and they also completed regular medicine checks and audits to ensure safe and appropriate medicines practices. When we reviewed medicine audits, were found these were being used effectively to identify and improve standards in this area.

People were happy with the medicines support they received. One person told us, “They [staff] make sure they always give me tablets on time. I asked them to make sure I have my tablets first thing and they always do.”