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 provider was in breach of 2 legal regulation in relation to safe care and treatment and fit and proper persons employed.

This service scored 62 (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. Incidents and accidents were reported when required to the local authority and appropriate action taken in response to keep people safe.

Systems were in place to receive national safety alerts, and these were used to develop safe practice. People and their relatives told us they were confident they would be informed about any incidents, and action would be taken to mitigate risks.

The provider collaborated 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 people had initial assessment documents in place which covered all appropriate areas. Two professionals told us the service collaborated well with them, 1 professional told us, “I would say that the service works well with other agencies. I have been in and conducted joint visits with social workers and have witnessed the service working well with adult services to support people’s needs,” The registered manager told us they were working with external teams to enhance collaboration and had arranged a meeting to address any concerns. The professional involved told us, regular meetings between the team and registered manager were in place to help to address issues. A relative told us when their relative required support, “There was a pre-assessment, they went to the hospital to see my relative and had discussions and completed the initial assessment with us; I was involved all the way, it was a smooth transition.”

The provider collaborated 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 provider shared concerns appropriately with the local authority safeguarding team.

The provider did not always make sure people’s care and treatment was effective by thoroughly assessing and reviewing their health and care needs with them.

Assessments were undertaken to identify risks to people and to the care staff who supported them, people told us they participated in this process. People and relatives were positive about the service received; however, we found risk assessments were not always robust and did not always contain sufficient information to guide staff how to support people safely. For example, in relation to epilepsy, choking and constipation. Staff had received appropriate training, knew people well and were able to describe the action they would take, to keep people safe. However, there was a risk staff would not always support people appropriately without clear guidance to refer to.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Relatives told us people had access to specialist equipment such as walking frames, wheelchairs and hoists. Records showed equipment in place had been assessed and maintained to ensure people’s safety.

The provider had not completed all the required pre-employment checks prior to recruiting staff to ensure only appropriate staff were employed to work with people. They had not sought satisfactory evidence of conduct in all relevant previous employment nor verified why the staff members' employment in those positions had ended. Staff’s recruitment records included Disclosure and Barring Service (DBS) checks.

The provider used a dependency tool to determine the safe staffing levels required to support people safely. We reviewed staff rotas which showed there were enough staff to meet people’s needs. We observed there were sufficient staff throughout our inspection.

The provider ensured staff received support, supervision and development. They had a training matrix in place which evidenced most staff had completed their statutory and mandatory training. Staff supervisions were mostly taking place in line with the provider’s policy.

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. The provider had an up-to-date Infection Prevention and Control (IPC) policy. Staff attended IPC training. We reviewed cleaning schedules which were consistently completed. People and their relatives told us the home was clean, and we observed this.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

One person was prescribed 2 paracetamol every 4 to 6 hours, records showed there was not always a 4-hour gap between administrations. This occurred on 18 days in April and May 2025. This put the person at risk of harm. We made a safeguarding referral about this.

Some ‘when required’ medicines did not always have protocols in place; however, where ‘when required’ medicines protocols were in place they did not always contain sufficient detail to guide staff how to administer medicines safely. For example, how staff were to administer a person’s liquid pain medicine or for medicine to manage constipation. This placed people at risk of not receiving their medicines when needed. We also found a person’s liquid pain medicine had not been administered as prescribed and they did not receive a sufficient dose of this medicine to manage their pain.

We found when people were prescribed topical creams and ointments, these were recorded in different areas. The provider conducted monthly cream administration audits to ensure these were administered consistently.

People had received their routine medicines as prescribed. Staff completed medicine training and were assessed as competent to administer people’s medicines safely.