Archived: Blakehill Healthcare Wiltshire

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 inadequate. 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 legal regulation in relation to safe care and treatment.

This service scored 28 (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 based on openness and honesty. Lessons were not always learnt and shared with the staff team to continually identify and embed good practice. Incidents were not always appropriately recorded which meant they could not be learnt from. For example, on 11 January 2025, a member of staff recoded on daily notes that they had administered a person’s medicine, however, they had not signed the electronic MAR sheet. The MAR sheet recordings showed as ‘medication not being administered’. There was no system in place to highlight to the manager there was a conflict in recording, so it was not appropriately addressed. One family member had raised a complaint with the provider about safe care. Whilst this issue had been logged, the provider could not demonstrate they had investigated the complaint or identified any lessons learnt and cascaded these to staff to prevent reoccurrence.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety in an appropriate way.

One person was supported by staff with the management of a complex health issue. However, health care partners and the person’s family had written 2 different versions of guidance for staff to follow in order to manage the person’s health issue. The provider had not identified nor addressed this conflicting information with either party, nor had they clarified with staff which guidance should be followed. This meant that staff were confused about what to do, putting the person at risk of poor support.

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. Staff understood what safeguarding was and could identify what to do if they felt people were at risk. Most people and their families told us they felt safe with the support the received from staff, however some people and their families’ raised concerns of safety with us. One relative told us they felt they needed to give guidance or be present with staff as they were not confident that safe care was always being provided to their relative. The relatives said they had raised this on several occasions with the provider but did not feel this had been appropriately addressed.

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

Risk assessments were not always in place to ensure people received safe care, for example not all people had fire risk assessments in relation to the creams they used. As some creams prescribed for use by people were paraffin-based, which carry a fire risk. This put people at increased risk of harm. The manager confirmed they would ensure the relevant risk assessments would be written.

The provider did not always have oversight of potential risks in the environment in which their staff worked. They did not always make sure equipment, facilities and technology supported the delivery of safe care. One person told us staff had left a front door unlocked when leaving a property on several occasions which put the service user at risk. Another person told us staff left bed rails up on a person’s bed overnight restricting their ability to get out of bed if they wished. Managers had received a complaint in relation to the bed rails and had messaged staff asking them to ensure they were put down before they left.

One person had a continuous positive airway pressure (CPAP) machine, however, there were no records to demonstrate staff were trained to use the machine, nor were they supporting the person to use it every night. Furthermore, there were no records to demonstrate that staff were cleaning it daily. This was raised with the manager who agreed to address the irregular use of the machine. A guide to cleaning the machine was sent to inspectors after their visit.

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

Risk assessments were not always in place to ensure people received safe care, for example not all people had fire risk assessments in relation to the creams they used. As some creams prescribed for use by people were paraffin-based, which carry a fire risk. This put people at increased risk of harm. The manager confirmed they would ensure the relevant risk assessments would be written.

The provider did not always manage the risk of infection. The provider did not always have the correct systems in place to ensure they had enough personal protective equipment (PPE) for staff to use when visiting service users. Some staff told us they had run out of PPE. The nominated individual and manager of the service confirmed there had been an issue with PPE but stated they had provided staff with appropriate equipment from their personal stock. The provider acknowledged there had been an issue with the delivery of an order of PPE from overseas, however they had sought PPE form other places to try to keep adequate stock available for staff. At the time of our onsite visit, PPE stock had been sourced and was available to staff.

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

One person had a medicine that needed to be given a minimum of half an hour before food. However, their daily records demonstrated they were regularly being given this medicine after food. This meant the medicine was less effective than it should have been. The provider failed to record the correct information within their MARs to enable staff to know the medicine needed to be given at a specific time. Providers audits and reviews of records had not identified this issue.

Two people were taking medicines that put them at risk of bleeding. People on this type of medicine are at higher risk of serious bleeds, particularly if they hit their head. However, there were no risk assessments in place to guide staff on what actions they should take in case of these people falling.

One person’s medicine had changed in October 2024, this had been provided in a blister pack with other medicines by their pharmacy. Staff had not identified the change to medicines and were signing they had dispensed this medicine despite it not being present in the blister pack. Audits had failed to identify this discrepancy in order for the provider to take appropriate action prior to our onsite visit.