Blakesley House Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified a breach of regulation in relation to good governance. The provider's systems and processes for monitoring and improving quality had not always been effective. The systems for monitoring and mitigating risk were not robust enough. Some of the practices at the service placed people at risk. There was a lack of staff awareness for some of the safety processes.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were not always aware of some of the provider's policies and procedures. Some staff told us they needed more information at handovers when they started work for each shift.

The provider had not utilised staff meetings or discussions with staff to help discuss and promote the shared direction of the service. For example, discussions and information sharing about the aims and objectives of the service, changes in regulation and good practice guidance or key procedures.

Staff felt their equality and diversity needs were met.

The provider had a culturally diverse workforce. They had a range of policies and procedures designed to support staff.

Most staff told us they found the manager supportive and good to work with.

Improvements were needed to the way leaders ensured staff understood about policies and procedures. For example, understanding the fire procedure. The leadership regularly asked staff to work excessively long hours which was not consistent with best practice.

Some staff told us they did not feel confident speaking up. Most of the staff did not know which outside agencies they could contact if they had a concern.

There were procedures in place, but these had not always been effective because staff did not fully understand about these.

Staff did not have a clear understanding of some of the governance systems. For example, they were not always carrying out sufficient checks on health and safety or medicines. This meant that they did not always identify when things went wrong. The manager told us they were researching ways to implement a digital recording system. At the time of our assessment, all records were paper based.

Audits were not always effective. The checks on the environment, medicines and records had not always identified where there were problems. Furthermore, there were not always action plans in place to explain how concerns would be rectified. The staff carried out regular medicine audits. However, these audits failed to identify the concerns related to medicines management we found during the inspection. We were not assured that medicine audits were being used to effectively highlight areas for improvement in the service. There was a process for asking people for their views through surveys. Although not everyone had opportunities to give their views. People told us they had not been involved in planning or reviewing their care. Records were not always clear or well maintained. Some information was not recorded, and some records were not clear or accurate. This meant that there was not always governance oversight. For example, following up on expiry dates and identifying themes with adverse events.

People using the service did not engage with local communities.

We did not receive any feedback from staff about this aspect of the service.

We did not receive any feedback from partners about this aspect of the service.

The service worked well with healthcare partners. However, there were no formal processes to help engage and work with other community groups.

Staff did not always have a good understanding of how to make improvements happen.

. The service has been breaching Regulations at the last 4 inspections. Breaches identified at our last inspection had only been partly met. At this inspection, we identified further breaches of Regulations. This indicates that systems for learning and improving the service had not always been effectively implemented.