Blenheim Court 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has improved to good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of the legal regulation in relation to safe care and treatment. Improvement was found at this assessment, and the provider was no longer in breach of this regulation.

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. There was a learning culture in the care home, which the new manager was improving. Staff were aware of procedures to follow to report and record incidents. We saw accidents and incidents were reviewed and analysed by the manager to identify themes and trends and feedback was provided to the staff team. This was through daily flash meetings and regular team meetings. Staff told us communication had improved, and they were listened to ensuring lessons were learnt.

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. We saw evidence in care plans of visits and referrals to health and care services when required and information was shared and reviewed to ensure people’s needs were met.

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 registered manager shared concerns quickly and appropriately. Staff understood safeguarding procedures and reported incidents immediately to management. Staff were confident the manager would respond appropriately. People told us the staff were good and made them feel safe.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. 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 people's capacity was assessed in line with MCA and decisions were made, where people did not have capacity, in their best interest. The manager kept a record of all DoLS with expiry dates and any conditions were detailed in peoples plans of care.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things which mattered to them. Risks associated with people's care were identified and managed effectively. The manager told us, “We involve our residents and their families in the resident of the day so we can ensure a holistic review of risk assessments and ensuring appropriate safety equipment is in place. The risk assessments are reviewed monthly in line with resident of the day or before if there are any changes. The risk assessments are available for all staff to view on the care plan system.” We saw risk assessments were in place and regularly reviewed.

The provider did not always detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, we found emergency exits were not monitored to ensure the temporary boarding, in place while building works were ongoing, was safe and secure. We found it was dislodged and unsafe. We also found lack of storage with hoists and wheelchairs stored in the communal lounge and a screen in place which was unstable. The manager addressed the issues immediately and included the emergency exit checks in their daily walk rounds. These safety checks need to be embedded into practice to ensure people’s safety.

The provider did not always make sure there were enough qualified, skilled and experienced staff deployed to meet people’s needs. The new manager was improving staff support, supervision and development. Staff worked well together to provide safe care that predominantly met people’s individual needs. The manager showed us the dependency tool used to determine staffing levels and staffing was provided in line with the tool. However, from our observations and feedback from people, relatives and staff we found staff were ineffectively deployed and at times there was lack of care staff available to meet people’s needs in a timely way. We observed domestic staff and the activity co-ordinator assisting with care and support on numerous occasions and care staff assisting with some kitchen duties, which took them away for their caring roles and responsibilities.

Staff said there were not enough care staff on duty to meet people’s needs. Staff told us they did not regularly get breaks and felt they had to rush care and support. They said people were wet as they had to wait to go to the toilet and could not spend the time they wanted when assisting people with eating. People told us the staff were lovely, very caring and kind. The only area of negative feedback was there were not always enough staff available to meet their needs and they were often rushed. One person said, “I've wet myself about an hour ago. I have asked them [staff] 3 times to take me to the bathroom, but they still haven’t done.” Another person said, “The thing that grates the most is, if I press the buzzer for the toilet, they [staff] pop their head in and say five minutes and then it can be 30 minutes later.”

Since our visit the provider has agreed to increase the staffing hours at weekends, they confirmed in writing this commenced from 6 September 2025. The manager has also looked at more effective deployment of staff and has changed some ways of working to improve outcomes for people. They assured us they would continue to work with staff to ensure adequate staff were available to meet people’s needs

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. However, some areas of the environment were not well maintained so were not able to be effectively cleaned. These included, storerooms, sluices and some equipment, for example, fixed toilet handrails, raised toiled seat, extractor fans and microwave. The manager has since our visit added these to the action plan and had addressed some issues immediately.

Staff had access to appropriate stores of personal protective equipment (PPE) and access to infection prevention and control policies. Audits we reviewed, identified areas for improvement and the provider had an environmental action plan that was being followed to make improvements.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning where appropriate, including when changes happened. Administration of medications was managed safely. Members of staff had access to policies and procedures which supported safe clinical practice. Staff were knowledgeable on peoples’ medicines and specific requirements. Staff were trained and received competency checks. We observed staff administering medicines safely and staff were able to explain people’s medication needs. However, we identified some ‘as and when’ PRN medication protocols lacked detail to guide staff. Following our site visit we received evidence from the manager confirming these had been reviewed and amended.