Blythgate 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.

This is the first inspection of this service. This key question has been rated 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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff learned from safety alerts and incidents. Any incidents about people's safety were discussed with staff in a timely way, with action taken to mitigate further risks. We saw action that had been taken to help reduce the risk of choking where people received a modified diet. Catering staff plated and named people’s plates. A staff member commented, “There is better labelling of food when it comes from the kitchen and people are supervised at mealtime in the dining room.” However, we discussed that systems needed to be strengthened to ensure where people received a modified diet, they were served the correct meal to ensure their safety.

Staff at the service worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. A professional commented, “When we have asked for further information, such as medical history, the nursing team have always been forthcoming with this information.” Staff made sure there was always continuity of care, including when people moved between different services. Detailed information was collected before people started to use the service, and passports were available with information to take when attending hospital or other health appointments.

Staff at the service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately. A staff member commented, “We have completed online and face to face training, and we are encouraged to report any concerns.” People and relatives told us they felt safe, they said they would speak with staff if they were worried.

Staff worked well with people to understand and manage risks by thinking holistically. Staff provided care that met people’s needs and was safe, supportive and enabled people to do the things that mattered to them. Risks were assessed to ensure people were safe and staff took action to mitigate any identified risks. Care plans contained detailed information for staff to follow to understand how to keep people safe, including how to respond when people became distressed.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. Equipment was regularly serviced to maintain safety. A person commented, “I am moved with a hoist and staff know how to help me properly, so I think they have been trained.”

The provider usually made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, there were occasions of high agency staff usage which people felt impacted on the service. In addition, improvements were needed to staff deployment to ensure there were sufficient numbers of different gender staff on units. We observed some female people became visibly upset and distressed at the prospect of being supported with personal care by male staff members. When we discussed this with staff and the provider, they told us and rosters showed people usually had a choice of gender of carer. We were assured that there had been exceptional circumstances on the day of inspection.

Staff members confirmed they received opportunities for training and development. A staff member commented, “There is online and face to face training.” Staff worked together well to provide safe care that met people’s individual needs. A person commented, “Staff pop in regularly, but I can use my call bell if I need anything.”

People and relatives thought there were sufficient staff, however they told us there was a large number of agency staff. Not all people and relatives commented that agency staff knew people’s support needs as well as regular staff. Relative’s and people’s comments included, “There are too many agency staff”, “The care has been superb but now there is a shocking lack of regular staff” and “There sometimes seem to be all agency staff at weekends, and they don’t know the residents. That is a big worry for me.” A staff member commented, “Agency staff have a log-in to the electronic system and can access information about people easily.” A professional told us, “When there is a full complement of staff, they look after their patients incredibly well. There are occasional times when they have to use agency staff when care has not been as good as we would have liked due to staff not knowing patients or just the fact that they are stretched.”

Staff assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff told us personal protective equipment (PPE) and all cleaning materials needed were available. They confirmed they had received infection control training. A professional commented, “The environment is brighter, cleaner, and far more welcoming.”

Staff at the service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened to people’s medicines. Records of regular medicines were well-maintained and followed national guidance including recording people’s allergies.