Blackberry Hill

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 changed to 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.

This service scored 59 (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 have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice. The provider had systems in place to report accidents, incidents, or safeguarding concerns. Staff demonstrated a clear understanding of how to raise any concerns. Incidents were routinely discussed during handover. Lessons learned from incidents were shared with staff. However, learning was not always embedded, and records were not always consistently updated to reduce the risk of reoccurrence. For example, following a near miss incident on the stairs a lessons learnt report had been completed, however the persons care plan had not been updated to ensure staff had access to relevant and up to date guidance. For another person who had previously gone missing, a risk assessment was in place, however this person did not have a missing persons protocol. We discussed the concerns with the management team who rectified them during the inspection.

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.Systems were in place to coordinate safe care, including health appointments and liaison with professionals. Records of people’s care needs were kept so they could be shared with others, and people had up to date hospital passports to support smooth transfers into acute settings. One professional told us, “The care team and managers have always been very supportive of our triage process. They have provided us with accurate and timely information related to their clients’ needs. They have always come across as caring and willing to discuss their clients’ health and support needs in an open manner.”

The provider did not always concentrate on improving people’s lives or protecting their rights as they did not always adhere to the principles of the Mental Capacity Act (MCA) or ensure that people’s rights were safeguarded. 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. We found that the provider had imposed restrictions on some people without properly assessing these or ensuring they were agreed as lawful. Improvements were needed to ensure decision specific mental capacity assessments and best interest decisions were in place for all restrictions, and that the restrictions in place were proportionate and the least restrictive option. For example, some people had restricted access to the kitchen and their ensuite bathrooms. Whilst there were mental capacity assessments and best interest decisions in place for locked doors, they were not decision specific and there was limited evidence to demonstrate less restrictive options had been considered. Another person had some of their belongings locked away with no mental capacity assessment and best interest decision completed. Where needed, applications were completed to authorise a person being deprived of their liberty. However, the restrictions in place were not always detailed within these applications. We discussed the concerns with the management team who told us all restrictions will be reviewed.

There were “See Something, Say Something” posters displayed around the home. Staff had completed safeguarding training. They told us they felt able to raise concerns and were confident they would be listened to. Comments included, “I definitely would be able to speak with the manager if I had concerns” and “I’d go to the senior, manager, local authority or police. I’d go to the Care Quality Commission (CQC) too.”

The provider did not always work well with people to understand and manage risks. Although care plans and risk assessments were in place, with areas covered including specific health conditions, choking, mobility, falls and epilepsy, these were not consistently detailed or up to date, and some key risk areas required further clarity. For example, 1 person’s bowel management plan was not accurate within their care plan. For 2 other people further details were required within their care plan to ensure staff had all the information they needed to enable them to be safely supported with their health condition. We discussed the concerns with the management team who rectified them during the inspection.

Risk assessments were completed to enable people to take part in activities. Risk assessments included the support people needed to safely access community facilities such as the cinema, pubs and coffee shops.

The provider did not always detect and control potential risks in the care environment. We identified some hot pipes were exposed which could potentially cause a risk of burns if a person fell against them. A fire risk assessment completed on 5 November 2024 had also identified significant shortfalls, which had not all been actioned. This placed people at risk. We discussed the concerns with the management team who started to rectify the issues during the inspection. We contacted the local fire service regarding our concerns. The provider told us they would also be contacting the fire service for advice.

The service had a system for environmental checks; however, these were not being consistently completed, and gaps in checks were identified. An audit completed by the provider had identified this concern and plans had been put in place to address this.

A relative shared concerns, and our observations confirmed, that at times the home could feel crowded and noisy in some areas. For example, during lunch we observed 1 person being supported by staff who were not able to sit next to them due to space, and at times lots of people were outside of the office in a small area. The registered manager told us they had previously recognised the main corridor as a higher risk area for incidents within the service. A risk assessment was in place.

The provider did not always make sure there were enough qualified, skilled and experienced staff. We received mixed feedback regarding staffing levels. Staff told us there were enough staff to meet people's needs. However, some relatives didn't always feel there were sufficient staff.

The service had a fire risk assessment completed on 5 November 2024. This raised concerns regarding the services evacuation strategy and staffing levels during the night. The management team were unable to provide details regarding how the current staffing arrangements had been assessed as safe. During the inspection a further fire risk assessment was completed and staffing levels increased at night.

Staff were recruited safely and received support, supervision and development. They received appropriate training including how to support people with a learning disability and autistic people. Staff spoke positively about training opportunities, including vocational qualifications and skills development, with one staff member saying, “I get an opportunity to do my learning, and [manager] is supportive of that”.

The provider assessed and managed the risk of infection.The environment was generally clean, an odour was noted in one bedroom and discussed with the registered manager for action. Staff had completed IPC training and personal protective equipment (PPE) was readily available. One staff member told us, “Plenty of PPE and chemicals, it’s very good.”

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.Staff were able to describe the process of medicines management in line with the providers medicines policy. Staff received training for medicines-related activities and were competency assessed. We saw people were given their medicines as intended by the prescriber. Medicine administration was personalised for individuals and their preferences and wishes were respected. Protocols to support staff administer PRN (when required) medicines was mostly in place. These included guidance on when and how staff should administer the PRN medicines. However, when people were prescribed more than one medicine for the management of the same condition, or when variable doses were prescribed, the protocols lacked specific guidance. However, this was rectified by the provider on the day of inspection and protocols were updated to include additional information. We saw people who were prescribed topical medicines had topical medicines administration records in place to support staff apply these as directed by the prescriber. Medicines related audits were carried out regularly and actions were taken to make improvements.