Archived: Blakesley House Nursing Home

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 remained requires improvement. Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to medicines. Staff did not carry out regular stock checks for controlled drugs (CD) to identify discrepancies. Record keeping of CDs had been raised as a concern during the previous inspection. Some staff did not know how to respond in the event of a fire and needed more guidance in this area. The environment needed updating, however, people told us they felt safe living at the home. Risk plans contained enough information for staff to meet people’s needs safely. Staff had a good understanding of protecting people from harm and how to raise safeguarding concerns.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessonswere learnt to continually identify and embed good practice. Staff told us they had attended meetings and discussed incidents and accidents. Staff said they learned lessons from these events. Feedback from the local authority confirmed the provider had an improved procedure in place to learn from safely incidents. In a case we reviewed it was clear that additional measures had been put in place. This meant the person’s health improved. The case highlighted lessons had been learned, and improvements had been made as a result.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service worked with external health care professionals to ensure people received timely care. Referrals to health care professionals were made in a timely manner. The provider shared a recent case with us which showed the person had a safe transfer between the home and the local hospital.

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. The local authority shared information with the CQC regarding any recent referrals made by the provider. The provider had acted in a timely manner. The provider had shared information about a safeguarding referral which showed there was a clear process in place. Staff were able to explain different forms of abuse and how to report any concerns.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk management plans within care plans were in good detail for staff to follow. Staff understood people’s care needs well. However, some staff were not clear on the procedure for fire evacuation. Some staff would benefit from further training on the fire procedures within the home.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. During our visit we observed that the environment was clean and free from hazards. However, the home needed updating. Some relatives and people told us the home was clean but old and tired in places. We were not provided with any documentation to confirm what systems were in place to check for any potential health and safety concerns, for example we did not see any health and safety checks or audits of the environment.

There was enough staff on duty to meet people’s needs. Staff had an induction into their respective roles and training was provided for them. Staff were recruited safely. People and relatives told us, “There is a nurse here the whole time. If I have any problem, they will come and see me. They take your blood pressure if you have any sort of problem to make sure that you are ok.” A person said, “Yes, they have enough staff. They are doing their job ok.” We were unable to verify what training was provided to staff as we did not have access to training documents. However, people and relatives told us that staff were able to do their job well and had received training. Recruitment of staff was done safely by the provider. Following our visit the local authority confirmed that staffing levels had been reviewed, and a new rota was in place.

The provider assessed and managed the risks of infections. There was a cleaner on duty each day. Staff wore personal protective equipment such as gloves and aprons. People and relativestold us the home was clean. Staff were able to explain how to prevent the spread of infections. There was an up-to-date step by step process in place following a recent outbreak of influenza.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines management training was also raised as a concern during the previous inspection Medicines including controlled drugs (CD) were stored securely and at the required temperatures. However, staff did not carry out regular stock checks for CDs to identify discrepancies. Record keeping of CDs had been raised as a concern during the previous inspection. Some people were prescribed medicines to be administered on a when-required basis (PRN). However, information in care plans or PRN protocols were not always in place or person-centred to administer these medicines consistently. For example, one person who had diabetes and was prescribed insulin did not have a protocol for the medicine prescribed to prevent hypoglycaemia.

Medicine care plans in place were very similar and not person-centred to help staff support people with their health needs. We could not verify and seek assurance that staff members had received training and were competency-assessed to handle medicines safely. We did not receive any training documents from the provider. The policies including the medicines management policies were sourced from an external company. We were not able to seek assurance if staff members had read these policies and followed them. The staff carried out audits, however, the audits failed to identify the concerns for medicines management we found during the inspection. There was no process in place to receive and act on medicine alerts.