Blackwater Mill Residential Home

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed 3 quality statements within this key question. We found 2 breaches of the legal regulations in relation to consent and meeting nutritional and hydration needs. Assessment tools were not used effectively to minimise risk to people. People’s needs had not been fully assessed and staff lacked clear and consistent guidance on how to support them and meet their needs. This could place people at risk of harm. There was a lack of routine monitoring of people’s care and treatment to ensure positive and consistent outcomes. We found consent to care and treatment was not always sought in line with the law and guidance. People gave mixed feedback about the food available within the service. Some people received food of an inappropriate texture to meet their needs and keep them safe, others had received food that was not in line with their personal preferences. People and staff reported a shortage of snacks and food available during the evening.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives expressed frustration at the lack of coordination regarding changes and 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.” A relative explained how they observed their loved one’s legs were not elevated as required to reduce swelling. They reported staff had been unaware of the need to elevate the person’s legs and said it was not in the care plan. Another relative said, “Many times I have mentioned a concern and I later discover it has not been put onto his file.”

Staff told us they found it difficult to support some of the people admitted to the service effectively. One staff member said, “We have very challenging residents in the home at the moment with high needs, which I believe is due to the poor standard of assessment.” They added, “Staff are faced with outbursts of aggression daily. [Senior member of staff] recently told us off for the high amount of incidents we were recording but I'm not entirely sure what they expect. Surely, they know what the individual's behaviour is like if they carried out a full and comprehensive assessment?"

Records did not provide a clear indication of people’s needs. Information was found to be lacking dates and in places to be contradictory or incorrect. One person had a specific behaviour relating to other people recorded. This was found to be inaccurate. For another person information about their weight loss differed between the nutrition and Malnutrition Universal Screening Tool (MUST) assessments. There was a lack of clear and person-specific guidance for staff relating to specific conditions. For example, Asthma was not detailed under the breathing section in one care plan and Chronic obstructive pulmonary disease [COPD] was listed but with no detail recorded. One person was noted as having Parkinson’s but with no information about how this affected them. The lack of clear guidance put people at risk of receiving inappropriate or inconsistent care.

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. One vegetarian had been given a meat dish according to the records in place. People and relatives commented on long waits when they requested drinks. One person told us, “I was always so hungry while I was in there you know it's extraordinary, I mean I haven't felt hungry since I came home.” A relative said, “I think the dinner is organised but the teas are a bit hit and miss – soup and sandwiches and sometimes cheese on toast, small portions what you would give a child.” A person assessed as requiring pureed meals to reduce their risk of choking had been given soup for lunch and tea over the course of 6 days. This was because the blender in the home was broken. A representative of the provider quickly arranged for a new blender to be purchased once this was brought to their attention. A relative raised concerns about their loved one’s support with eating and drinking. They told us the person often appeared very thirsty. Other times they described visiting and seeing uneaten meals and drinks in the person’s room. They said, “Where they cannot sit up on their own, they need full assistance, but they just leave the cup there. When I go in sometimes, I give [loved one] 3 drinks because they are so thirsty.”

Staff told us there were limited options to give people if they requested a snack during the evening or night. One staff member said, “We need more food that we can give to residents. We can be really limited on what we can give, not usually much option. If someone is diabetic might only be able to find cakes or biscuits which isn’t the best option.” Another staff member described the budget as “incredible” when they first started but told us it, “keeps getting lower and lower.” They said, “It’s very demoralising.” A representative of the provider advised the budget had increased with inflation.

Assessment tools were not used effectively to minimise risk to people. In an audit of Malnutrition Universal Screening Index (MUST) scores, those with a score of 2 were noted to ‘monitor’, yet the tool indicates a score of 2+ as high risk with advice to ‘treat’. Some care plans referred to people requiring fortified meals and having snacks between meals and at bedtime. We found however the latest time for a snack given was recorded at 6.21pm. Staff told us there were limited options for nutritious snacks to offer people during the evening and nighttime. There was conflicting information in assessments relating to the same risk. For one person’s risk of skin breakdown, their care plan recorded ‘low risk of pressure injury’, yet their Waterlow assessment (used to identify and manage pressure ulcer risk) indicated areas of pressure damage and score that corresponded to ‘risk of pressure injury’. Repositioning records indicated that people were not being repositioned in the time frame they had been assessed as needing to maintain skin integrity. Care plans contained conflicting information and gaps, for example guidance to weigh a person was weekly in their care plan and monthly in their nutrition assessment. From the records provided, this person had not yet been weighed since they moved to the service some three months earlier. Another person was noted to have food allergies in their care plan but food allergies was recorded as N/A within the food allergy section. Where people had been assessed as requiring a fortified diet, this was not always recorded on the board in the kitchen. One person required a milky full fat hot chocolate around 8.15pm but records indicated their last hot drink offered before 6pm. Staff had not received appropriate training in modified food textures. The failure to meet the nutritional and hydration needs of people was a breach of Regulation 14 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

One person described how they were not allowed to go out alone. This person had capacity and was not subject to Deprivation of Liberty Safeguards (DoLS). They had been prevented from leaving the service independently, although the service had no legal justification to restrict their movement. The same person had sensor mat in place, which they had not agreed to. A sensor mat alerts staff when the person gets up/steps on it. Another person speaking about showering shared, “I am told when this is and not asked when would like one.” Relatives of people who were unable to consent to their care had not been asked for their views or involved in best interest decision making. One relative said, “‘Never had a meeting, only spoke about covid vaccines. Not had any meetings regarding other decisions or best interest decisions.”

We discussed with a senior staff member how a person had indicated they were being prevented from going out independently. The staff member told us the person had full capacity and there was no legal process in place to detain them, yet they felt they needed someone with them when they went out due to a medical condition. The staff member added the person was due to go home to live independently. Some staff showed a lack of knowledge and understanding of the principles and application of the Mental Capacity Act 2005.

Mental capacity assessments for people with a diagnosed impairment to the mind or brain were completed up to 2 months after admission. There was no evidence people were provided information to make informed decisions and consent to their care. This included assessing the person’s wishes and ability to consent to personal care, support with their medicines and living within a setting where the external door was locked. Where people had equipment in place to alert staff to their movements, this had not been assessed as a restrictive measure and to be in their best interest. Mental Capacity Assessments and Best Interest Decisions were not fully completed. For example, some best interest decision records did not include the date of the conversation or elaborate on the action being taken and why it was deemed to be in the person’s best interest. There was no evidence people were provided with information to make informed decisions and consent to their care. We found examples of best interest checklists completed by senior team members indicating an advance decision to refuse treatment (ADRT) was in place, yet there was no evidence to support this. A senior staff member explained their understanding that if a person has a DNACPR in place then this constitutes an advanced decision. However, unlike an ADRT, a DNACPR form is not legally binding. The provider had failed to ensure people’s consent when using their images or recordings on their public social media account. People we spoke with were not aware their images had been shared. There were shortfalls in staff training on mental capacity and consent, with approximately 40% of staff training in this area showing as out of date or not completed. The failure to ensure consent was a breach of Regulation 11 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.