Blossomfield Rose Care 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.

This is the first assessment for this service since registration. This key question has been rated Good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

People told us they felt safe and supported by staff who knew them well and listened to concerns. Staff understood the importance of reporting incidents, with systems in place for them to do so.

Policies guided staff in managing safety events, and lessons learned were reviewed by managers to make changes and improvements. The manager told us that they had made significant changes to a lounge area following an incident. They had then completed a full assessment of all communal lounge areas.

Healthcare professionals told us the service responded appropriately to requests for changes in people's care needs.

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.

Pre-assessment processes were in place and arrangements made for both service users and family members to be involved in all decisions about their care.

We saw evidence people returning to the service following hospital stays were supported by staff to enable a safe discharge home. A person told us “They [staff] came to see me on the ward before I came home and made sure I had everything I needed to be safe.”

People told us they had been given information about the service and, where possible, visited the service before going to stay there.

Staff told us they were informed of the needs of people prior to them moving into the service. Basic information was shared at meetings prior to people moving in and care plans and risk assessments were developed with people.

Healthcare professionals reported the service made referrals to appropriate partners where required.

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.

We observed people appeared to be well cared for and had positive relationships with the staff who supported them.

Staff had received training in recognising signs of abuse and were aware of the processes to follow if they had concerns. Staff understood the need to obtain people's consent prior to supporting them and were aware of people who had restrictions in place and why.

People told us they felt safe when supported by staff. People and relatives were confident that if they raised any concerns, they would be listened to, and appropriate action would be taken.

A person told us, “You won’t believe how nice they [staff] are. I haven’t heard a raised voice since I have been here.” Another person told us, “If I had any concerns, I could talk to any of them [staff], but I have no concerns.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff included people in managing risks and respected their choices.

Staff were able to explain the risks to the people they supported and felt care plans and risk assessments gave them the information they required to support people safely.

However, in some cases, risk assessments lacked clear and up-to-date information and guidance for staff on how to manage risks to people or held conflicting information. For example, one person’s risk assessment stated they were cared for in bed; however, we observed them in the lounge area. Their risk assessment had not been updated to reflect they now had the necessary specialist seating to access the lounge. We raised these issues with the provider who addressed these immediately.

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 inspection we observed that safety was proactively managed. Doors which should be were always locked, and maintenance of the home was of a high standard.

A dedicated maintenance team ensured environmental safety checks were completed, and any issues attended to in a timely manner.

The manager was able to share examples of where incidents had taken place, and actions had been taken to minimise future risks to people.

People had no concerns regarding their living environment and felt safe.

The provider did not have a robust system for ensuring staff received effective supervision and appraisal.

People were supported by staff who had been safely recruited. Staff received an induction which included mandatory training and shadowing more experienced colleagues before working on their own.

Staff did not receive regular supervision. For example, we found there were no supervision records for 2 members of staff, and another member of staff had not received a documented supervision for over 12 months. The registered manager acknowledged this concern and told us they were taking steps to make staff supervision more consistent. In addition, there were no records of annual appraisals for staff.

Staff received training which reflected the duties they were required to fulfil and the needs of the people they supported. People said they felt staff were well trained and complimented them on their kindness and compassion.

People told us on the whole, staff respond to call bells in a timely manner, but had observed staff were very busy which was something they were concerned about. Staff being 'rushed off their feet' was a phrase we heard from some people and their relatives.

The manager told us there had been a recent change to how staff were deployed across the service. This was being monitored and reviewed regularly. However, the provider did not have a robust system for assessing staffing requirements in line with people’s current and changing needs, such as the use of a dependency 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.

During our inspection we saw the home was clean, tidy and free from unpleasant odours. The care staff were supported by a team of housekeeping staff who took pride in their work.

Staff had received training in infection prevention and control. There were checklists and audits to ensure that all areas of the service were cleaned regularly. There was enough personal protective equipment (PPE) available, and we saw that staff used this PPE during care tasks.

People and their families told us that their rooms were cleaned regularly and that the housekeepers worked hard to keep the home clean.

The provider did not always make sure people’s medicines were safely managed.

We found the supplies of people’s medicines held on site were not always effectively managed to avoid stockpiling.

Where people had been prescribed time-sensitive medicines, these were not always administered in line with the prescribers’ instructions.

Staff did not always record the date of opening on people’s medicines. We found 1 person’s eye drops and another person’s liquid pain killer were in use with no date of opening recorded of either medicine.

Oxygen cylinders were not always stored safely and securely.

Although monthly medicines audits had been completed, these had not enabled the provider to identify and address these concerns.

We did not identify any harm to service users as a result of these shortfalls. We raised these issues with the registered manager, who took prompt action to address of these concerns.

Staff administrating medication were trained and had their competencies assessed.

People told us they were supported to receive their medicines as prescribed and that they had no concerns regarding their medicines management.