Blackwater Mill Residential Home

Updated 1 March 2024

Date of assessment 19 March to 3 May 2024. This assessment was completed following concerns about managing risk, safety of the home environment and support with personal care. We carried out an assessment, including site visits on 19, 20, 25 March and 12 April 2024. In total, across the different visits, the team involved 6 inspectors, a medicines inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. People were placed at risk of harm because risks were not appropriately assessed and managed. There were ongoing risks related to the stairwells, fire safety, managing distressed behaviour and ensuring people received food modified to an appropriate texture to meet their needs. People’s ability to consent to their care or restrictions in their support had not been assessed inline with the law and this impacted on their human rights. Staff did not have consistent guidance to enable them to support people safely. They had not received regular training to enable them to meet people’s varied needs. Issues identified in previous inspections and actions noted by the service in their audits had not been sufficiently addressed. We identified nine breaches of regulation. This included continued breaches relating to safe care and treatment and good governance from 2021 and 2023. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

Updated 1 March 2024

Some people did not feel safe at the service. One person had recently been assaulted by another person who used the service and wanted a lock on their bedroom door so they could feel safe at night. People told us they had not always consented to restrictions in their care. One person was not being allowed to go out independently and others had a sensor mats to alert staff to their movement. These restrictions had not been assessed in line with the law. People and relatives expressed frustration at the lack of coordination regarding updates to their care. One person said, “Staff do listen to our concerns, but it often does not get to the relevant person or takes time to respond.” Another told us, “As to whether staff listen to my concerns very much depends on who I speak too.” Some people did not feel confident their concerns would be listened to and others were not sure who to contact. Feedback included, “I don’t feel the staff listen” and, “There’s got to be a boss somewhere.” Some people told us they did not receive support in line with their preferences to bath or shower. One person said, “I have a bed bath but would like a shower.” We received feedback about irregular medication times and some medicines not being available to people when they needed them. People gave mixed feedback about the food. Some people’s preferences had not been respected, for example if they disliked fish or pork this had been served to them. People told us they were not always able to access drinks snacks, particularly in the evenings. People who were unable to join in the planned activities, were not supported to engage in meaningful activities and appeared to have limited interaction. People shared concerns about the cleanliness and hygiene within the home. However, people gave positive feedback about the staff team. One person said, “They [staff] are very good, lovely, I have no concerns.” A relative shared, “I’ve only observed kindness to Mum and others.”