During an assessment under our new approach
Date of assessment: 30 December 2025 to 9 January 2026. Blenheim House Care Home provides nursing and personal care to 69 people at the time of the assessment. The service can support up to 85 people who are over and under 65 yrs and who have dementia. This assessment was carried out to follow up on action we told the provider to take at the last assessment. The service was in breach of regulation for good governance. At this assessment we found the service was no longer in breach of regulation.
The service now had more effective governance systems to assess quality and safety. However, further improvement was needed to sustain and embed the improvement seen. We found some hazards in the environment which had not been fully assessed for risk. The provider took action to remove these hazards and review safer ways of working. Some people with risk management plans had conflicting information recorded. Whilst there was a system to regularly review care plans, further actions were needed to make sure they were consistently providing guidance for staff.
Since the last assessment there was a new registered manager in position. They were being supported by the provider with regular visits from central office staff. There was a daily head of departments meeting which enabled leaders to discuss events, incidents, complaints and changes to ways of working. Staff worked in partnership with a wide range of healthcare professionals. Professionals told us the new registered manager was approachable and responsive to feedback. Staff told us they were well supported and felt able to approach all members of the management team.
Staff were recruited safely and had an induction when starting work. Regular refresher training was provided, and staff had the opportunity to complete work-based qualifications. There was enough staff available to safely meet people’s needs. Where there were gaps in the staff number’s, agency staff were used.
The service was clean and well maintained. Health and safety checks had been completed for equipment and facilities. Regular checks for the fire safety system were carried out, and staff were involved in fire drills to practice responding to fire alarms.
The provider had taken action to improve medicines management. However, we found some time specific medicines had not always been given on time. People had a personalised medicines administration record and there were no gaps in recording. Medicines were being stored safely and regular audits for medicines administration were being completed. Not all actions from the audits had been added to the provider’s data systems. This meant it was not clear who was responsible for completing the actions and by when. This was addressed during our site visit.
Lessons were not always being learned in response to all incidents. Whilst there was improvement seen with the electronic incident forms and reviews, we found behaviour monitoring forms were incomplete. There was no consistency with the paper forms being used and staff recording was not detailed enough to provide all information of what had happened.
Staff had applied to the local authority for Deprivation of Liberty Safeguards (DoLS) authorisations. However, when these had been authorised by the local authority, the service had not notified Care Quality Commission. The registered manager took action to submit notifications during the inspection.