Blenheim House 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.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice. When people experienced distress, staff recorded incidents on ‘ABC charts’ which were behaviour monitoring forms. This type of form enables staff to review people’s distress and identify trends or patterns in causative factors. Carrying out this type of work can help staff learn about and understand a person’s needs and effective ways of responding. However, we found there were various forms in use at the service and staff were not recording on them consistently. This meant when people had experienced distress it was not clear what had happened in all cases and what support had been provided by staff to assure the person. We found records of incidents where people had been distressed, followed by comments that the person ‘was content’. This was conflicting and did not provide information about people’s distress so that consistent approaches could be used to mitigate any risks and keep people safe.

Other incidents which were recorded on electronic records were completed thoroughly. Leaders reviewed these forms and ensured all actions needed had been completed. The registered manager told us staff were learning from incidents and discussing how to improve ways of working. They said, “We have weekly clinical risk meetings, we go into details about accidents and incidents. We have staff meetings every quarter and send out a weekly newsletter with updates for staff. Every Friday we do ‘learning lounges’ for the staff which will be on different topics.”

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.

When people moved between services staff made sure important information was shared with others. For example, if people were admitted to hospital, important healthcare information was shared with medical staff. When people were discharged from hospital staff re-assessed their needs and made sure they could be met safely at the service.

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 when people had DoLS authorised staff had not always added this to the person’s care plan. This meant staff would not know who had an authorisation and who was waiting for an assessment. We also found where people had conditions attached to their DoLS this had not been added to their care plan. This meant the service could not easily demonstrate how they were meeting all conditions. Management took action during our inspection to update people’s care plans.

For some DoLS authorisations we found the service had not notified CQC. Providers are required to notify CQC of all DoLS authorisations and any conditions attached. The registered manager told us they would submit the required notifications without delay.

Staff had been provided with safeguarding training and understood what their responsibilities were to report any safeguarding concerns. The registered manager had reported concerns to the local authority and worked with professionals to resolve safeguarding incidents.

People told us they felt safe at the service and would raise any concerns if needed. People liked having call bells including pendant alarms around their neck. People said this helped them feel safe.

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.

Risks to people’s safety were not clear in risk management plans. There was conflicting information which did not provide staff with accurate details of people’s individual needs. For example, 1 person at risk of falls had conflicting information about the number of staff they needed to transfer and mobilise. Another person had conflicting information about their risk of constipation. For 1 person with diabetes, there was limited guidance on signs of ill health for this condition. There were no details on what action staff would need to take if they noticed the person’s health condition worsening. Leaders responded to our feedback about these shortfalls and said they would amend people’s records.

Staff knew risks to people’s safety were recorded in personalised care records. Staff said they discussed risks in daily handovers and at staff meetings.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff had taken steps to provide support to people which created hazards in the environment. These hazards had not been fully assessed to consider risks to everyone living in the area. For example, staff had placed a low picket fence around a person’s door. This was to prevent people entering the person’s room which caused them distress. The risk of trips and falls around this hazard had not been considered for everyone mobilising in this area. Following our site visit, staff told us this hazard would be removed, and other safety measures would be considered.

We found a door to a person’s room was being held open by a large armchair. This meant in the event of a fire, the door would not close, which put people and others at risk. Whilst the action was added to the person’s risk assessment, it was not evident the service had considered and assessed the risks for others. After our site visit the registered manager told us they were taking steps to remove this risk.

At our last inspection the service was not managing the risk of legionella safely. At this inspection we found improvement had been made and systems were effectively monitoring water systems for the risk of legionella. Health and safety checks were being regularly carried out by maintenance staff and external contractors. This included checks for equipment and premises such as lifts, hoists, gas safety and emergency lighting.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff had been recruited safely and provided with an induction when starting work. Further training was provided when needed and covered areas such as dementia, moving and handling, basic life support and supporting people with learning disabilities. Staff had supervisions with their supervisors and opportunities to attend staff meetings.

We found there were enough staff available to meet people’s needs. Some people told us they had to wait at times for their call bell to be answered. People did not say there was any impact from waiting but we shared this feedback with the registered manager. Our reviews of call bell response times for the month prior to the inspection did not identify any delayed responses.

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.

Staff were provided with training on infection prevention and control and if any guidance changed, further refresher training was provided. Staff had personal protective equipment to use and had been provided with training on how to use it safely.

People told us they were happy with the cleanliness at the service. Staff kept their rooms and communal areas clean. We observed the service was clean in all areas.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People who required time sensitive medicines did not always get them consistently on time. This shortfall had been identified in medicines audits prior to this inspection. However, actions taken had not made the improvement needed. Whilst we found no evidence of harm, it is important for people needing this type of medicine to have them at the prescribed times.

Medicines audits were completed and had been increased to weekly in response to a number of medicines errors. However, shortfalls found during audits had not always been added to the provider electronic system. This meant it was not clear who would be responsible for completing the action and in what timescale. The quality director took action during our inspection to address this shortfall.

People did not share any concerns about their medicines. They were happy with the support they had from staff to manage their medicine.