Blythe Rose Care Home Also known as 1-12948766437

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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. Lessons were learnt to continually identify and embed good practice.

Accidents and incidents were reviewed monthly to identify trends and agree what was working well or needed further action to reduce future risks. Staff confidently described reporting processes, explaining they used electronic systems and could escalate concerns to senior staff or raise them during daily meetings. One staff member told us, “I use our systems to report accidents and incidents. I can raise concerns with the clinical lead, managers or at the daily 11 o’clock meeting.” Staff also described reviewing previous incidents to identify patterns. Relatives confirmed they were kept informed, with one telling us, “I’m notified of incidents straight away, usually before I get chance to check the daily log.” This meant there was a strong culture of learning which protected people from avoidable harm.

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 held weekly multidisciplinary meetings with health professionals to plan admissions safely, support continuity of care, and review people’s medicines, diagnoses and any additional staffing needs. People and their families told us they were fully involved throughout the pre‑assessment process. They were able to visit the home, meet the team and take part in a clinical review to confirm their needs could be met. People moving into the home received 1-1 support for the first 24 - 48 hours, and staff reviewed which area of the home would suit them best. One relative shared, “The admission process was very positive and staff communication has been excellent,” while another described it as “smooth” and said the home was “accommodating.” A further relative told us, “The first few nights were difficult, but staff reacted quickly to settle [person]. Over time they’ve got to know them well and manage their care safely.” Staff described clear admission processes, including pre‑assessment paperwork and a moving‑in checklist.

Technology was used to support safety, communication and reassurance for families. Relatives shared that they could access daily updates through an application on their phone, “I can see my loved one’s information on the app… I feel they are safe here… staff always check with me before any changes.”

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 and relatives told us they felt safe. One person said, “I feel safe here… there haven’t been any concerns,” and a relative told us, “I feel my loved one is 100% safe.” A small number of relatives raised concerns about people who walk with purpose entering other people’s bedrooms and about aspects of weight management and skin integrity. On review, we found appropriate risk assessments had been completed and effective measures put in place to manage these risks and maintain people’s safety. Another relative we spoke with highlighted the importance of the locked door system in protecting people, saying, “People have the right to be in their bed asleep without intrusions”. Doors could be locked from the outside to prevent unwanted disruptions while still allowing the person inside to exit freely. Health professionals were positive about the service, telling us they had “no concerns at all” about safety or the quality of care.

Staff received safeguarding training and showed a clear understanding of how to recognise and report concerns. They described monitoring for signs of abuse and escalating issuesto senior staff. One staff member said the training “provided a good basis” for their day-to-day work, and another explained that injuries were documented and shared during handovers so that staff could continue monitoring. Staff also received training in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). One staff member told us their training emphasised involving people in decisions wherever possible, not assuming a lack of capacity, considering family input, and always choosing the least restrictive option. Mental capacity assessments were decision specific and explored the least restrictive approaches for each person, and DoLS authorisations were tracked and updated regularly.

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 assessments were in place and reviewed regularly. One staff member shared, “The needs assessment is an ongoing process, and careful consideration is given to where new people reside in the home. People can however move to another lodge if more appropriate later on.” Staff had the training and guidance they needed to support people safely. We found risk assessments and care plans were clear and outlined measures on how to reduce risk. For example, one risk assessment and care plan outlined how one person required two to three staff for personal care, dependent on how the person was on the day, with only one member of staff communicating to reduce distress, and protective equipment such as low‑level mattresses and impact mats were used to keep them safe. Another person had a risk assessment and best‑interest decision for locking their bedroom door during protected time to prevent unwanted intrusions from people living with dementia who walk with purpose within the home. This was clearly documented and regularly reviewed. Staff also followed risk assessments for specific behaviours, such as redirecting and supervising people where needed. Where gaps were identified in risk assessments during our assessment, such as people using key fobs without supporting risk assessments, the provider told us they would address this.

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 well maintained and easy to navigate, with dementia‑friendly colour schemes, clear bathroom signage and good natural light. However, during the assessment we found some areas requiring improvement. Kitchenette counters that were meant to be locked when staff were not present were open on the first day, although these were locked during subsequent visits. A small number of signs did not accurately reflect the rooms they referred to, though the manager had already requested updated signage. We also found that some staff were unsure of fire procedures and a few fire doors had been wedged open. The provider responded quickly by delivering refresher training, improving signage and planning more frequent fire drills to ensure procedures become fully embedded.

People and relatives described the building as “welcoming” and “tidy”. Bedrooms were personalised with names and familiar items to support recognition, and the home offered a mix of communal areas and quieter spaces. Some rooms had balconies with appropriate safety measures, outside spaces were secure, and window restrictors were in place throughout. Routine maintenance checks were completed, and any issues were dealt with promptly.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Support systems such as training, supervision and induction were not consistently effective.

Views about staffing levels varied. Some staff told us there were times when only one member of staff was left to oversee the lodge, and some relatives raised concerns about agency staff not being familiar with people’s needs. One relative said the home was, “over reliant on bank staff”, although they described permanent staff as, “excellent”. Recruitment processes were mostly robust, but there were minor gaps in employment histories and reference checks. Supervisions and appraisals were inconsistent, and only a small proportion of agency staff had completed the induction process. There were also gaps in agency staff training, including dementia, learning disability and moving and handling. Staff views about having time to read care plans were mixed.

However, we saw no unsafe staffing levels during the assessment, and staff appeared to know people well. Permanent staff had high training compliance and demonstrated good knowledge of their roles and the people they supported. Relatives described staffing as, “generous” or said it worked well in practice, and others told us regular staff were skilled, structured and worked effectively as a team. Another commented their loved one, “always has regular staff”. One staff member said, “When I joined, the staffing and occupancy wasn’t good, however the home manager has turned this around.” Health professionals also reported care staff, “Had been trained to provide high quality care for people with complex needs.”

The provider assessed and managed the risk of infection, and systems were in place to detect and control the risk of it spreading.

The home was clean, spacious and uncluttered, and relatives consistently described it as, “clean and well maintained”. However, we found some inconsistencies that required improved oversight, including blocked freezers, inconsistent food labelling, and items left unattended such as a staff’s drinks bottle. When raised with the manager, immediate action was taken to address these concerns. Staff had access to appropriate personal protective equipment (PPE), completed infection prevention and control training and demonstrated a clear understanding of barrier nursing, which we saw in practice during the assessment. Infection control policies were in place, COSHH products were secured, and the laundry room was clean and organised with a one‑way system to reduce cross‑contamination. Monthly quality assurance reviews monitored infections, and care plans included detailed clinical guidance for people at higher risk, including clear escalation processes and involvement from external professionals.

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

Medicines were managed safely, with secure clinical rooms, correct temperature monitoring and controlled drug registers showing no discrepancies. However, we did identify some areas for improvement, including one undated insulin pen and a clinical room briefly cluttered while new stock awaited checking in, though these did not affect the overall safety of practice. A relative told us they had confidence in the system, sharing staff were, “very knowledgeable” about people’s medicines. Staff and professionals described significant improvements in psychotropic oversight. Psychotropic medications are medicines that affect behaviour, mood, thoughts or perception and are used to treat a variety of mental health conditions. One clinical lead explained the use of lorazepam had, “reduced significantly”. This had been achieved through weekly multidisciplinary meetings involving the GP, psychiatrist and mental health team, which focused on safe deprescribing and involved families in decision‑making. One visiting professional described the home as providing, “excellent care” for people with complex needs and noted the positive impact of reducing these medicines. Care plans contained detailed behavioural guidance to ensure medicines were used only as a last resort, and we saw examples where people who were previously reliant on as and when needed (PRN) sedation no longer required it. Staff told us they felt confident in their training, with one commenting that medicines processes had, “improved massively”. Policies were in place to support safe administration and ongoing monitoring.