Bluebell Manor

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 inspection, we rated this key question requires improvement. At this assessment, the rating has changed to good. This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulations relating to staffing and good governance. Action had been taken to improve and the provider was no longer in breach of these regulations.

This service scored 75 (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 demonstrated a positive learning culture. They had taken action to address the breaches identified at the previous assessment and had used the learning from this to make improvements within the home.

Systems were in place to support ongoing reflection and learning among staff. Staff received regular supervision and attended meetings which provided opportunities to reflect on practice, share learning and identify improvements. A staff member told us, “Incident reviews are conducted constructively, with key learnings shared across the team to continuously improve care.”

Accidents and incidents were analysed to identify patterns, trends and opportunities for learning. The provider also used a range of governance systems, including audits, clinical governance reviews and analysis of information relating to areas such as falls, incidents, wounds, nutrition, hydration and medicines. Information from these systems was used to identify areas for improvement and support learning.

The registered manager told us analysis of falls had previously identified a pattern of falls occurring overnight. By July 2026, they stated there were no consistent patterns in the location or time of falls, which the registered manager and provider attributed to improvements made to the environment.

The provider worked with people, their relatives and health and social care professionals to promote safe systems of care and support continuity when people moved between services.

We heard and read examples of how staff supported safe and well-coordinated transitions when people returned home or moved to other services. An external professional involved in coordinating people’s care told us, “[Registered manager] and her team are always polite, professional, and efficient when I contact them with any questions, referrals, or enquiries.”

The provider and staff understood their responsibilities to protect people from abuse and were committed to keeping people safe.

Staff we spoke with demonstrated an understanding of safeguarding procedures. No safeguarding concerns were raised during our assessment. People told us they felt safe. A person said, “Yes, I feel very safe living here. The staff are kind, look after me, and help me when I need it.”

Systems were in place to monitor safeguarding concerns, including the recording and review of safeguarding referrals, actions taken and any learning identified. Staff received training in safeguarding, the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

The provider worked in line with the principles of the MCA and ensured people were supported to make their own decisions wherever possible. Where people lacked capacity, appropriate processes were followed to ensure decisions were made in their best interests and in the least restrictive way. The provider maintained oversight of DoLS applications and authorisations, where people lacked capacity, appropriate processes were followed to ensure decisions were made in their best interests and in the least restrictive way. Following the recent Supreme Court ruling, staff were reviewing DoLS arrangements with the local authority to ensure applications and authorisations remained appropriate and compliant with current legal requirements.

Staff involved people and those important to them in assessing and managing risks, to ensure care was both safe and enabling.

People and relatives said people were safe. One relative said, “Safe – yes, the staff are absolutely wonderful with her.”

Electronic risk assessments were in place and were reviewed regularly and when people's needs changed, this helped ensure risks were identified and managed appropriately.

Staff worked with people, relatives and healthcare professionals to balance safety with choice, independence and wellbeing. People were supported to use equipment and technology that promoted their independence while managing associated risks.

The environment met people's needs. The provider had invested in an extensive programme of redevelopment and improvements to the home, including the garden and outdoor areas. This included improvements to lighting, furniture and colour schemes, as well as adaptive seating with lumbar support to promote people’s comfort, wellbeing and safety.

People and most relatives spoke positively about the home environment. A relative said, “They've got a nice garden. She likes sitting in the garden, we're impressed with it all.” Some feedback suggested areas within the home, including the Bluebell male only suite could be made more homely and a person also commented that the call bell could be noticeable at times during the evening and at night.

The provider ensured there were enough suitably qualified, skilled and experienced staff to provide safe and effective care.

Staff received the training, support and supervision they needed to carry out their roles effectively. A staff member told us, “I feel supported in my role and have opportunities to develop my knowledge and skills.” People and most relatives felt staff were well trained and able to meet people's needs.

There were sufficient staff deployed. Whilst some people and relatives thought staff were busy at times and more staff would be appreciated, we observed staff carrying out their duties in a calm unhurried manner. People and relatives told us they were familiar with many of the day staff who supported them. Some reported less consistency amongst evening and night staff, including the use of agency staff. The registered manager explained that staff turnover was low and the same agency staff were used alongside permanent staff to provide greater familiarity for people. New staff had been recruited for the opening of the male only Bluebell suite.

The provider completed a range of pre-employment checks to help ensure staff were suitable for their roles. They liaised with organisations within the local community to support recruitment. An external employability provider told us, “They have successfully supported 3 of our candidates into care assistant roles over the last year.”

The provider assessed and managed the risk of infection and took steps to prevent its spread.

People spoke positively about standards of cleanliness. A person said, “My room is always clean and tidy and so is the home.”

Staff had access to and used Personal Protective Equipment (PPE). Infection prevention and control was monitored through handwashing and IPC audits, as well as clinical governance meetings. A local NHS infection prevention and control practitioner told us they had delivered training to staff.

Medicines were managed safely and people received their medicines as prescribed.

Staff followed appropriate processes for the safe storage, administration and disposal of medicines. Management staff provided examples of working in line with STOMP (Stopping Over Medication of People with a Learning Disability, Autism or both) principles to reduce the use of medicines where appropriate and ensure people received the least restrictive support to meet their needs.