Boldmere Court Care Home Also known as 1-341197990

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 the same.

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 regulations in relation to safe care and treatment and protecting people from the risk of abuse and neglect.

This service scored 53 (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. Staff did not always investigate concerns in enough detail to inform future practice. Lessons were not always learnt to continually identify and embed good practice.

Although systems were in place to identify and share lessons learned across staff teams, some risks were overlooked. During our assessment of the service, we shared concerns with the provider about inappropriate staff conduct towards a person which was witnessed. The conduct did not cause physical harm to the person but did result in them being unnecessarily restricted. The incident occurred in the presence of other staff who did not intervene. When the investigation into this concern was shared with us, it only addressed the conduct of the one staff member. It did not acknowledge the presence of others, or their failure to intervene. We raised this with the provider who told us the investigation did require further work, which they assured us would be conducted to ensure the investigation was sufficiently thorough.

Although analysis of incidents and accidents was conducted by the registered manager each month, some themes and trends were not identified or explored in detail. For example, we saw no evidence that individuals who needed support with specific risks had incidents related to these risks analysed. This meant learning in relation to how to mitigate these risks was not as effective as it could have been and opportunities to improve support and reduce the risks could have been lost.

We did see that falls analysis was detailed and learning was drawn from this to reduce the risk of falls for people.

The provider did not always manage or monitor people’s safety consistently. This meant there was a risk of people not receiving the care they needed from external services.

We found examples whereby people had sustained blows to the head. However, there was no evidence they had received the monitoring and support to determine whether their condition needed to be escalated to emergency services. This meant some people had not received the care needed to mitigate the risk of head injuries.

However, we saw other examples of the staff team working well with other services and health professionals. For example, the support of the tissue viability nursing team had been sought for people with pressure injuries. This had enabled people with pressure wounds to receive timely effective care to help their wounds to heal.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

We found staff responses to safety concerns were inconsistent. For example, one person sustained an injury whilst in the care of staff. The injury was treated in hospital and the incident was recorded. However, there was no investigation to review the decisions and actions taken by staff to ensure the person’s safety had been a priority at all times. We also saw a person had been found to have sustained an injury but could not tell staff how it happened. We saw no evidence of an effective investigation into how the injury could have occurred.

Staff had however completed safeguarding training and could tell us how they would share concerns about people’s safety if they had any.

We saw some examples of detailed investigations into safeguarding concerns, which considered how events could inform preventing future risks.

The registered manager maintained a system to seek Deprivation of Liberty Safeguards (DoLS) for people who may struggle to consent to or make informed decisions about their care. DoLS authorisations give care home staff legal authority to restrict people’s freedoms when it is strictly necessary and in their best interests. If any authorisations specified particular conditions, we saw evidence of how the conditions were being met. Mental capacity assessments were conducted when people moved into the home. DoLS authorisations were sought in a timely way.

The management team shared safeguarding concerns with external agencies in line with local agreements. This allowed others such as the local authority safeguarding team to apply scrutiny to concerns raised and promote safety of the people living at the home.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We identified the risk that some staff did not fully understand what physical restriction was. This was based partly on our observation where a person was physically prevented from doing what they wanted to do without intervention from other staff. We shared this with the provider, who responded with an action plan focused on monitoring and reducing the use of restraint.

A staff member later told us the management had reinforced the importance of recording all forms or restraint. They said staff had reported to management that one person was routinely being physically restrained to receive care, to the extent it had not always been recorded. Although staff confirmed they now recorded any use of physical restraint, we remained concerned that restraint was not consistently being used as a last resort. Discussions with staff suggested alternative approaches were not always considered before restraint was used.

Records relating to incidents of physical restraint often lacked sufficient detail, including the duration, method of restraint, and what steps had been taken to avoid its use. As a result, records did not always demonstrate that physical restraint was necessary and applied only as a last resort.

Guidance for staff on how to support people who may become physically aggressive when distressed, did not always contain sufficient detail. For example, we saw little information for one person about what

could trigger their distress, to help staff look out for early warning signs. We shared our concerns with the management team; they told us they would investigate the issues raised.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had conducted a detailed review of the safety and maintenance of the home environment. They had identified areas where improvement was needed and were working through an action plan to ensure any concerns identified were being addressed in a timely way. Equipment around the home had been reviewed to ensure checks and maintenance was updated. Fire safety systems and equipment were checked to ensure safety.

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.

Staff gave mixed views on whether they thought there were enough staff to support people safely. Some staff said there were not enough of them to meet everyone’s needs. Other staff said they thought the numbers of staff provided sufficient care support. Most staff we spoke with told us there were not enough of them to support people to remain meaningfully occupied. The registered manager explained 1 activity coordinator had recently stepped down from the role, and they were recruiting to replace them. There was 1 full-time staff member in place to support all 66 people living in the home with activities. They told us care staff were also being asked to help people with activities. Some of the care staff told us this was challenging because they often did not have any extra time to do this after they had carried out their care responsibilities. One staff member said, “They need to give us more support with activities. [The people living here] just sit and watch TV…we don’t have enough staff to take people outside.”

Some relatives told us they thought there were not enough staff to support people with activities. Some also told us they thought more care staff were needed. One relative told us, “I think they probably need more staff, it’s very hard for them on the [specific area of the home].” Another said, “I think they probably do need more staff on, we can be waiting up to 10 minutes to get in the front door.” However, two relatives we spoke with told us they felt there were enough staff to provide care for their loved ones. One told us, “I do think there are enough staff with the correct training for the job.”

The management team told us they used a tool to help them calculate how many staff were needed to meet the needs of people. They explained that this was reviewed regularly but was also reviewed at any time a person’s needs changed significantly.

Staff were recruited safely. Disclosure and Barring Service (DBS) checks were made prior to recruitment of new staff to ensure they were suitable for the role. Staff spoke positively about their induction. Compliance with mandatory training had been identified by the provider as needing improvement in some areas. Additional training and dates had been arranged to address this.

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.

People living at the service told us they were happy with the support they received to keep their home clean and tidy. Relatives also agreed that staff worked hard to maintain a clean environment and most relatives were happy with the support their loved ones received to maintain good personal hygiene.

Staff told us they always had access to sufficient supplies of Personal Protective Equipment (PPE). We saw staff using PPE appropriately during our assessment and found the home to be clean and tidy. Some areas of the home were being re-decorated during our visits.

During our assessment we observed some aspects of medicine management which were not reflective of the policies and procedures of the provider. However, we found these had not significantly impacted people and the provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

During our visits we did find some medicine management issues which we shared with the provider. The staff member administering medicines did not have their time protected and was called away from the task to support someone with a care need. Consequently, the medicines trolley was left unlocked and unattended. This created a risk of people being able to access medicines which were not safe for them. We discussed this with the provider who advised that staffing arrangements on the day had led to this error. They told us staff would be reminded about the importance of protected time to administer medicines.

We noted that when medicines were being administrated, the nurse did not practice hand hygiene in between administering medicines to different people. The provider advised that this was expected practice to help protect people from the risk of infection and that staff would be reminded about this.

We found that some guidance for staff regarding the administration of ‘as needed’ medicines could not be located during our visits to the home. We raised this and the management team ensured these were quickly put into place. One person who was prescribed a medication for times of significant distress, had guidance for staff which did not detail how to ensure it was used as a last resort. The management team responded quickly to this to ensure extra guidance was added and approved by the person’s GP.