Blossom Care For You LTD

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

During this assessment we looked at 3 quality statements in the key question of well led. The overall rating for this key question combines scoring from quality statements we looked at during this assessment and quality statements scores in line with findings from our last inspection. At our last assessment, the key question well led was rated requires improvement. At this assessment we identified shortfalls in the quality of care and the service remains requires improvement. We found a breach in regulation in relation to good governance. The provider did not have effective governance systems in place to monitor and improve the quality of care and safety of the service. The provider had not always reported significant incidents to local safeguarding teams or CQC as required. Records and documents requested by CQC as part of this assessment were not always in place or available for inspectors to review. The service had not had a registered manager in place since July 2021. The provider confirmed that the manager and office manager had both recently submitted applications to CQC to register as manager of the service. The provider and leadership team were receptive and open to our feedback throughout the assessment, making changes where possible to begin to make improvements in areas identified. The leadership team were working to foster a positive/open relationship with people and staff. People and staff told us the leadership team was dedicated, approachable and that since the change of provider earlier in 2024, there had been improvements made to the consistency of the leadership and care. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 50 (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 positive about the provider and leadership team. Staff were motivated in their role and had a good understanding of people’s needs. They were also positive about the culture in the service around how it had improved under the new owner.

The provider needed to submit an updated statement of purpose to CQC to reflect the range of services it was providing. Submitting an up-to-date statement of purpose to CQC is a requirement providers must complete. This helps CQC to gain an understanding of the types of services delivered by the provider and assurances around how people’s needs will be met.

Staff were positive about the new leadership team at the service. They told us they had made improvements including, ensuring staff had adequate travel time between care visits and improving staff rotas to ensure people had right amount of care at planned times. The manager and office manager were motivated and committed to people’s care. They told us they had a good relationship with people and staff and they would go out to deliver care if there was a need. For example, if there was an emergency or people required additional support.

The service had not had a registered manager since July 2021. The manager and office manager had recently assumed their roles and applied to CQC to register as managers for the service. They told us they had either obtained or were working towards additional qualifications in health and social care relevant to a management role.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The manager and office manager had recently assumed senior roles in the organisation. They told us they had yet to fully establish a regular set of audits and quality checks to effectively oversee the service. They told us the provider had invested in an electronic based compliance system to help them develop policies and audits. They said they were still in the process of reviewing this system to determine which parts were applicable to the service.

There was limited oversight of the quality and safety of the service. Documentation to support the judgements of this assessment were not always available for CQC to review. Senior staff were not always aware where requested documents were located or whether they had been completed. This included audits, incident reports and staff training records. The office manager and manager confirmed that some audits in key areas were not being completed. These included audits of care plans, incident records, safeguarding records and care records. Where audits had been completed, there was limited assurance that they were effective in identifying issues or driving improvements. Where audits were taking place, these had only recently started being completed, and processes were not embedded. For example, the manager had started to audit people’s medicines records. However, these audits did not identify the issues highlighted at our assessment. We found that the provider did not always submit statutory notifications to CQC as required when significant incidents took place at the service. We found examples of 3 incidents which met the notification threshold, but these were not submitted by the provider. The provider did not ensure that all their policies contained the required level of detail in line with best practice guidance. For example, the provider’s medicines policy needed development to ensure there were robust procedures for staff to follow around consent, PRN medicines and covert medicines. This meant there were not clear procedures set out for staff to follow to ensure they met best practice standards.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.