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 remained 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. The service was in breach of legal regulation in relation to people’s safe care and treatment and safe staffing.

This service scored 56 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The management team had not ensured lessons were learnt following our previous inspection in May 2024. We identified improvements had not been made. Therefore, new processes and good practice had not been embedded into practice. We discussed with the provider how identification of lessons learned and clear communication of learning to the staff team could be strengthened.

Staff were aware of the procedures for reporting and recording accidents and incidents. They explained the falls protocol and the steps to follow when someone experiences a fall. However, review, debriefs and analysis were not always conducted after incidents, and there was no formal sharing of learning among the team.

Family members shared they were generally kept informed of any changes in their relatives' needs. However, relatives did not feel their concerns were listened to or dealt with appropriately.

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.

We saw evidence in care plans of visits and referrals when required. People and relatives told us health care professionals regularly visited the service. Relatives confirmed their family member saw their GP and could request a visit if they felt they were unwell.

We reviewed care plans and saw information was shared and reviewed with health care professionals. However, it was not clear if advice and guidance had always been obtained from health care professionals when required. We observed best practice was not always followed when people were identified as having swallowing problems, which meant they were at increased risk of choking. Staff were able to give a detailed explanation about risk and how it was managed, however, there was no evidence in the care plan that the practice had been reviewed and deemed safe by an appropriate specialist.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

Risks were identified and documented in peoples plans of care. However, some lacked details and there was not always evidence of health care professionals’ guidance to ensure safe practices were followed.

Risks associated with fire safety and evacuation procedures had not been reviewed or updated following changes to the building due to ongoing extensive building works. Fire escapes and safe routes from the building had either been blocked or had staircases removed. Therefore, people had no safe accessible exits to use in the event of a fire. People’s personal emergency evacuation procedures (PEEP’s) had also not been updated or reviewed to ensure the information was up to date, detailing correct procedures to follow in the event of an emergency. This put people at risk of potential harm. Officers from South Yorkshire Fire and Rescue visited and the provider took action and initiated the company’s contingency plan while works were undertaken to ensure peoples safety.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

A staffing dependency tool was used. However, staff had to multitask. For example, on the day of our visit, the cook had called in sick. The activity coordinator had prepared the breakfast, the laundry assistant then prepared the main lunchtime meal, and in the afternoon, a senior care worker prepared the tea. This took staff away from their substantive roles.

Staff we spoke with felt unsupported and they did not receive supervisions. Staff morale was low, staff did not feel valued or listened to. Records viewed showed staff supervision, guidance, support and mentoring were minimal This meant care was not always person centred and deployment and mentoring of staff was not effective.

People we spoke with told us there was not enough staff on duty. They did not get regular showers or baths, and staff were always very busy. One person said, “I had a shower yesterday, before that I have not had one for 6 weeks.” People said staff were lovely but were very busy. One person said, “They [staff] don’t always come when you press the buzzer, I just keep on pressing and then get told off. Sometimes, in bed, they don’t leave the bell at the side of me, so I can’t ring, I don’t feel any independence, I panic. There’s not enough staff ever. Staff tell you they are short; it makes you wary of asking for assistance.”

Relatives commented there was lack of staff available. One relative said, “There’s not enough staff, when people ask for the toilet, they have to wait.” Our observations evidenced poor deployment of staff and lack of direction and support. One person said, “They have meetings at 7am and 11am and you can’t buzz then, they say you can’t have a drink as they are in a meeting."

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.

We carried out a tour of the service, the service was maintained to a clean condition. This had improved since our last inspection. The domestic staff were passionate about ensuring the environment was clean and well maintained.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.