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 good. At this assessment the rating has changed to 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 62 (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. Incidents and accidents were recorded but we found some did not contain accurate information. For example, in 1 incident staff had recorded the person had been aggressive with other people living at the service. This was not accurate. The management told us they were working with staff to improve record keeping. Management review of incidents had not always identified failures to take action where needed. For example, when people had fallen and sustained a head injury, falls protocols had not always been fully completed. Incidents had been closed on the provider electronic incident reporting system without identifying action needed to prevent recurrence.

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. Staff worked well with health and social care professionals. Comments from professionals included, “The seniors are good at flagging concerns to us. We get a list weekly and if staff are worried about someone acutely, they will contact the surgery, and we come out in between” and “Referrals have become more appropriate; it was poor before, but things have improved. This management combination is the best we've had here. [Nurse Care Manager] is clinically astute, [Deputy manager and manager] both listen and act.”

The provider worked 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 quickly and appropriately. People and relatives told us people were safe at the service. Comments included, “Yes, totally safe. I know someone is nearby all the time and staff check on [relative] during the night and day” and “Yes, [relative] is safe. [Relative] is well looked after on the nursing floor, there is more care. They [staff] keep an eye on things when they are not right.” Staff received training on safeguarding and understood what needed to be reported to management. Staff had applied to the local authority for Deprivation of Liberty Safeguards (DoLS) authorisations where necessary. Those approved did not have applied conditions.

The provider did not always work well with people to understand and manage risks. Risk management plans were inconsistent and did not always provide guidance to staff on how to support people safely. For example, in 1 person’s care plan it was documented, ‘Choking risk’ but there was no guidance for staff on how to reduce the risk or the action needed if the person did choke. Some people had been assessed as being at risk of falls. Falls prevention plans were in place and informed staff to ensure people had access to any mobility aids and were wearing well-fitting footwear for example. Post falls monitoring records were inconsistently completed. We looked at the records for 1 person who had an unwitnessed fall. The provider’s falls protocol had not been followed to document observations immediately following the fall. Subsequent monitoring was not recorded until the following day. Unwitnessed falls are a risk because staff cannot be sure a person has not hit their head, and the lack of monitoring meant there was a risk staff would not identify signs the person’s condition was deteriorating. The deputy manager showed us how the service analysed falls to reduce the risk of recurrence. We saw records of when staff had reviewed a series of falls, sought advice from external health professionals, reviewed the effectiveness of that advice and considered other falls prevention intervention, such as checking people’s prescription glasses were still correct. The deputy manager said, “We have falls huddles each week where actions are identified and followed through particularly for people who have have multiple falls.”

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. The provider used external contractors to monitor the risk of legionella. Following a monitoring visit the external contractor had identified actions needed to ensure the environment was safe. These actions had not been completed. The home manager told us they would organise the remedial action to be completed as a matter of urgency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. The home manager used a dependency tool to help calculate staffing numbers. Where there were gaps on the rota, agency staff were used. People’s feedback about staffing numbers was overall positive, though 2 people told us they felt there could be more staff. Staff told us they felt there were enough staff available. New staff had an induction when they started work and all staff had refresher training when needed. Staff had regular supervisions with their line manager where they could discuss any training needs. Staff had been recruited safely, though we did find 1 staff file with a discrepancy in dates of employment which had not been checked.

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 service was clean in all areas. We observed domestic staff cleaning all areas during our site visit. Staff had access to personal protective equipment (PPE) and we observed them wearing it when needed.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Whilst the provider had identified shortfalls in medicines management using their own quality monitoring checks, action had not been taken to make improvements. We have reported on this in more detail in the key question well-led. Some people were prescribed transdermal patches, but patch records were not consistently filled in. It was difficult to assess if manufacturer guidance on how often patch sites should be rotated had been followed, because of the inconsistent record keeping. Some people had been prescribed additional medicines on as required (PRN) basis. Although PRN protocols were in place, they were not personalised and did not provide staff with information on when and why people might require them. For example, one person was prescribed a medicine for ‘Extreme agitation’. The protocol did not inform staff what this meant in practice or what steps they should take prior to resorting to the use of medicines. Another person’s PRN protocol referred to staff ‘Trying other techniques’ but did not explain what these techniques were. Staff told us one person regularly asked for pain relief because of an old injury, but the protocol for this person made no reference to that. Bottles of medicines, eye drops and creams and lotions were not consistently dated when staff opened them. This meant there was a risk staff would not know when the contents had expired. Some people were prescribed anti-coagulants (blood thinners) which meant they were at an increased risk of bleeding if they sustained an injury. Although some people had anti-coagulant care plans in place, they were not in place for all people who were prescribed them. Medicine administration records showed people received their medicines on time, including those that were time specific. Staff had been trained and assessed as competent to administer medicines.