Blossom Lodge

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 newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, staffing, and premises and equipment.

This service scored 34 (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 based on openness and honesty. We could not be assured the leadership team always listened to staff about safety concerns due to feedback we received from staff about feeling listened to and concerns we found in relation to people’s safety. There was a lack of effective oversight to ensure risks posed to people were appropriately assessed, mitigated and managed. However, we found accidents and incidents were recorded and reported externally as required. Systems were in place to ensure the leadership team reviewed incidents and learned lessons from them.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Care planning was inconsistent, with conflicting information relating to nutrition, hydration and repositioning needs. This meant staff did not always have clear guidance to ensure safe and effective care could be given. We could not be assured information shared with partners would be up to date or correct, including information shared with hospital teams.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. We could not be assured people were kept safe from harm due to concerns we found relating to managing risks posed to people. We received mixed feedback from staff on whether they felt able to raise concerns with the management team. A staff member said, “I haven’t shared my concerns because the managers are not approachable.” Whilst another staff member said, “The managers are good.” However, people told us they felt safe living at the service. Whistle-blowing procedures were in place and staff received training relating to safeguarding vulnerable adults.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The service was not always working within the principles of the MCA. Whilst we found people had DoLS authorisations in place, people's capacity had not always been assessed. This included their capacity to make decisions about their care and support.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. For example, we observed unsafe moving and handling practices, including a person being moved in a wheelchair without footplates in place. Information relating to some people’s nutritional needs and pressure care were conflicting in care records. This meant staff were not provided with robust guidance to carry out people’s care in line with their needs. Where a person had self-injurious behaviours, there was little detail about this in their care plan, records did not provide information about how staff managed this and how staff promoted distraction techniques to reduce these behaviours. This placed people at risk of receiving unsafe care.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. For example, we found exposed wires, broken emergency pull cords, damaged walls, and missing shower plugs. We also found unsafe outdoor areas with overgrown grounds and uneven surfaces, and trailing wires in bedrooms, placing people at risk of trips and falls. Several radiators did not have covers, placing people at risk of burns. Following our assessment the provider covered all radiators within the service. We did find some equipment was maintained, such as lifting and electrical equipment, and people had equipment in place to manage some falls risks, such as bed rails and sensor mats.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. We observed people waiting for support, such as personal care and feeding. We observed periods where people were left unsupervised, including people at risk of falls. Most staff, people and relatives told us there was a lack of adequate staffing. Staff told us they often went without appropriate breaks. A person said, “They (staff) don’t bring enough drinks round.” A staff member said, “We are struggling, there aren’t enough staff. People’s needs are high. We have to ask other units for help, but we don’t get it.” Staff had received training in relation to their roles, however some face-to-face training was overdue, such as moving and handling and first aid. Staff were not always recruited safely. Whilst staff had pre-employment checks in place, risks associated with these were not suitably mitigated for a staff member and another staff members recruitment records did not contain an application form.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. For example, we found visibly dirty toilets, stained furnishings, stained flooring, exposed wood, limescale on sinks, shared unlabelled razors and toiletries and empty hand hygiene dispensers. Domestic staffing levels were not sufficient, and cleaning staff were sometimes redeployed to provide care.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines rooms exceeded safe temperature ranges, meaning medicines were not always stored appropriately. Controlled drug checks had not been completed for extended periods, and handwritten Medicines Administration Records (MAR’s) entries were not consistently signed by two staff. One person did not receive a prescribed pain relief patch on time due to lack of stock, this person received higher than usual medication for agitation over this period, indicating they may have been experiencing pain. Where people received as required medicines there was not always protocols in place to guide staff about when these should be given. We also found some medicines which were not counted, meaning staff could not suitably audit all medicines to ensure people received their medicines as prescribed. Audits were not robust, had not been completed for each area of the home, and failed to recognise or action concerns we found. Staff were trained prior to administering medicines to people and had their competencies assessed.