Blackwell Care Centre

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• 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

We identified 2 breaches in regulation in relation to medicines and staffing. We found areas where improvements were required for some aspects of the way medicines were managed. The provider has shared with us their plans to make the necessary improvements. Key information was not always shared with the staff team. This meant that staff’s lack of action could have resulted in significant harm. Where there were known risks to people, actions were not always taken to mitigate these. This meant people’s care was compromised as their needs were not being met. There were insufficient staff available to keep people safe so people were at increased risk of harm and injury.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

One relative told us they did not always feel their family member was safe at Blackwell Care Centre. They said, “I do not rest when I leave [family member]". Not all relatives told us they were informed of incidents which related to their family member. However, most people and relatives felt the home was safe.

Staff demonstrated an understanding of safeguarding, keeping people safe and free from harm. Staff told us they would report concerns to the registered manager and record important information. Staff we spoke with were not aware of Duty of Candour. The Duty of Candour is a regulation which all providers must adhere to. Under the Duty of Candour, providers must be open and transparent, and it sets out specific guidelines' providers must follow if things go wrong with care and treatment. The registered manager told us they had systems in place to monitor safeguarding concerns. The registered manager said they worked with local commissioners and healthcare professionals to keep people safe. They told us that if they are made aware of any concerns, they were acted upon.

People were not always observed to be safe. Staffing levels meant that communal areas were often left unsupervised which placed people at risk. Where people had fallen, records did not always show where this information had been handed over to staff. This meant people did not always have appropriate nursing observations in line with the provider’s post fall protocol. Medical advice was not always sought in a timely manner. This left people at risk of harm and deterioration in health.

There were multiple staff who were out of date with their safeguarding adults training, this included a senior member of staff. The provider’s systems failed to identify this was out of date. Systems were recently implemented to monitor safeguarding’s, however they had not yet been fully embedded at the service. Lessons learnt were not always identified which meant areas for improvement may not be addressed.

One relative told us that they were not always happy with the care their family member received. The relative raised concerns relating to the number of falls their family member had over a short period of time. The relative felt that the person did not always receive appropriate aftercare. This relative told us they were concerned the person was showing signs of being unwell and these were not acted upon. We were told that staff knew people well and staff were attentive.

Staff were able to demonstrate how they involved people in their care, including involving relatives, where appropriate. Staff displayed a good understanding of recognising where people may show signs of distress, and how to recognise changes in people’s needs. Staff told us they received training in dementia care. However, there was no specific training in supporting people with positive behavioural support. Leaders told us how they involved people and their relatives in their care. They told us how they encouraged people to maintain their independence whilst maintaining their safety.

During our site visits we observed people were left in lounges without any staff being present, and without means to call for assistance. We observed people shouting out for help and staff were not available to assist. For example, we observed 1 person walking around the home looking for staff. No staff were available to support the person. We intervened to support the person, as they were displaying signs of confusion and distress. We also observed people did not have adequate support during mealtimes. We observed 1 person who was left unattended by staff within a hallway to eat their meal. This person appeared confused and had taken another person’s meal. The person was receiving a modified diet and was at risk of eating foods which put them at risk of choking. We observed some staff provided support to people’s risks safely. For example, when moving and handling, staff explained the support they were providing. People were observed to have appropriate equipment in place to aid them to move independently.

Where people's known risks were identified, people's needs were not always acted upon to reduce the risks. For example, where people were at risk of skin breakdown, records we reviewed showed that people were not being repositioned in line with their care plan. We identified 3 people whose care plans stated they should be supported to reposition every 4 hours at night. Records showed the time between repositioning at night exceeded this. This meant people’s skin integrity was compromised as their needs were not being met.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives we spoke with told us they did not feel there were enough staff at Blackwell Care Centre, and this had an impact on the care people received. Not all relatives felt staff received enough training to do their job effectively. Although people and relatives felt there was a lack of staff, they all told us that staff were friendly and, ‘do their best’.

All staff we spoke with told us there was not sufficient staffing’ at Blackwell Care Centre. Staff were concerned people's care needs were not being fully met due to this. Staff told us when there were new admissions, staffing levels were not increased to reflect this. One staff member told us, "I feel under pressure, and I am scared that I cannot respond to people in a timely manner". Staff told us they felt the size of the building had not been considered in relation to staffing levels. Staff did not always feel they received enough training to do their job effectively and staff were not always given enough shadowing opportunities. The registered manager told us there was minimal agency use and where needed, the provider aimed to use regular agency workers to ensure consistency of care.

On the first site visit, there were more staff available. We were told, “Staff were asked to come in. I received a call that morning and I was asked to come in as soon as possible”. On our second visit to the home, there were not enough staff on duty to ensure people’s needs were met safely. Staff were rushed and were focused on task-based interactions with people. There were no staff allocated to support people in the communal lounge and some of these people were at high risk of falling.

The provider’s training matrix identified that a number of staff were out of date with key training which meant that people were at risk of receiving care from staff who were not suitably trained. The provider had a dependency tool in place to identify the safe level of staffing per the number of people who lived at Blackwell Care Centre. On review of the provider’s rotas and the staff observed on duty during both staff visits we saw there was a shortfall of staff.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were supported to receive support with their medicines in a way that met their individual needs and preferences. Staff were polite, gained consent before administration of medicines. Relatives told us they felt medicines were well managed and no concerns were raised.

All staff we spoke with were not aware of how to report medicine errors in line with the providers policy, this included a senior carer who was responsible for medicines administration. Staff who were responsible for administering medicines told us they were often distracted by people and other staff when they are administering medicines, leading to more errors. The registered manager told us of the systems to ensure medicines were managed safely. For example, daily walk arounds and peer checks. However, from our findings during this assessment, these were not effective.

A number of medicine errors were found during this assessment. Medicine stock counts were not accurate; therefore, we could not determine that medicines were always given to people as prescribed. Although the provider had systems in place to monitor medicines, these were not effective in identifying any discrepancies. Where discrepancies in stock were identified, these were not always acted upon. The provider did not have a robust system in place for staff to report medicine errors. Therefore, the provider was not able to monitor trends and patterns, including any lessons learnt. We found medicines that were not stored in line with the manufacture’s guidelines, this meant that people were at risk of ingesting food supplements which may not have been safe for use. The provider’s training matrix showed that staff who were responsible for administering topical creams did not receive training in medicines or were assessed as competent to do so. This meant people were at risk of receiving their topical medicines unsafely, or to the wrong site.