Blackwater Mill Residential Home

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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 assessed 7 quality statements within this key question. We found 5 breaches of the legal regulations in relation to safeguarding, consent, safe care and treatment, staffing and fit and proper persons employed. The breach relating to safe care and treatment was a continued breach of regulation. Risks to people's health and safety had not always been identified and guidance to staff on how to mitigate them was not always available. People did not always have updated care plans to guide safe practice. People were not always protected from harm and some reported feeling unsafe. Learning from incidents was not consistently recorded or shared with the staff team to raise awareness of risk and embed good practices. Consent to care and treatment was not always sought in line with the law and guidance meaning people’s human rights were not protected. Staff had not had sufficient training to enable them to meet people’s varied needs. Clearer guidance was required for staff to support the safe administration of medicines, for example medicines prescribed on a when required basis or with a variable dose. The provider had not completed all necessary recruitment checks. Potential risks in the care environment and with the use of equipment had not been adequately addressed. Areas of the home and some equipment was not clean.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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, sometimes they do and sometimes they don’t” and, “There’s got to be a boss somewhere.” A relative shared, “There have been a few issues, resolved only after many complaints.” Another said, “Many times I have mentioned a concern, I later discover it has not been put onto [name’s] file.” People felt confident staff would help if they had an accident.

Staff told us they received limited or no feedback following incidents they reported. One staff member told us they had reported 3 safety concerns. They said 2 of the 3 were shared in handover but added, “We don’t get feedback.” Another staff member told us, “I know we have forms, I go to [staff member] for advice.” A third shared, “I can’t remember what the incident form looks like.”

Governance and oversight processes for staff learning and service improvement across the home did not always lead to improved safety and quality of care for people. Despite the use of a Service Improvement Plan, which showed the manager and nominated individual communicated and acknowledged outcomes of audits, there were basic fire safety and environmental risks which had not been promptly addressed. The provider had failed to respond sufficiently to previous incidents of harm to learn and mitigate risk within the service. We found a lack of action had been taken to mitigate the risk of choking and that people continued to receive food that was inappropriate to their needs. One person assessed at level 5 (minced and moist) on the IDDSI framework was given sandwiches for most of their teas. IDDSI level 5 information on foods to avoid is ‘No regular dry bread, toast and sandwiches due to high risk of choking’. Another person assessed as requiring staff assistance and a soft diet was found alone with a fried egg they were attempting to eat whole. Staff had not received appropriate training in modified food textures. Similarly, a lack of appropriate action had been taken to mitigate the risk of people falling down the stairs. The provider had installed stair gates, but these were not fit for purpose and were found unlocked or open throughout our visits. By the final day of our visit measures had been taken and the new stair gates were appropriate and linked to the fire alarm system. Previous highlighted concerns relating to guidance for staff around specific medical conditions, including Asthma and seizures, had not been responded to. Care plans were not sufficiently detailed to support staff in caring for the person if their medical condition exacerbated. We found many staff did not have the training they required to provide safe care. We found gaps in knowledge about mental capacity assessment and risk management approaches.

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 person told us they wanted a lock on their door so they could feel safe at night. The person stated that they are currently putting their walker under the door handle to stop people from coming in their room. This person was recently assaulted by another person. A representative of the provider subsequently confirmed a lock had been installed. Another person was prevented from leaving the service independently, although the service had no legal justification to restrict their movement.

Staff said they found it difficult to support some of the people admitted to the service as they did not have all the skills or resources to meet their needs. One staff member told us, “We have very challenging residents in the home at the moment with high needs.” 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?"

People's preferences in relation to their personal and intimate care needs were not being met and some people appeared unkempt. Staff did not attend to people's personal care needs when needed, even when asked. One person was sitting in wet clothing. We informed staff of this. After 20 minutes we checked to find the person had a clean ‘Kylie’ sheet over their lap while their clothes underneath remained wet.

People were placed at risk of actual harm and had been assaulted by a person known to the service as displaying physical aggression when distressed. This person was assessed as needing a sensor mat to alert staff when they leave their room, yet this was not in place during our visits. The provider failed to keep people safe by ensuring the documented risk mitigation was in place. Due process not been followed which impacted on people's human rights. We found applications had been made to deprive people of their liberty (DoLS) though their capacity had not been assessed and no best interest decision had been undertaken. Where people had and authorised DoLS in place, conditions had not been met. Of the senior team, half of the team were overdue training in DoLS. The failure to ensure consent was a breach of Regulation 11 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. An unexplained injury to a person resulted in 6 stitches to their earlobe, described in the accident report as 'torn in half'. Care plans and risk assessments showed minimal information around the incident. We were not assured of a full investigation to establish the cause of this injury. Not all incidents that met the threshold for a notification to CQC had been reported. You can read more in the well-led section of this report. Personal care charts reviewed indicated people were not getting baths or showers for up to 3 months in some cases. This shortfall had been identified in audits by a representative of the provider in May 2023 and the trend continued up to and including March 2024. There were shortfalls in Safeguarding training, with over 60% of staff training showing as out of date or not completed. Of the senior team, half of the team were overdue training in DoLS. The failure to protect people from abuse and improper treatment was a breach of Regulation 13 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Most people told us they felt supported. One person said, “I have a stick which I use in my room. I need staff to help me up and downstairs.” One person, however, said, “Staff know what you need but don’t always do it.” Another was concerned by other people who used the service coming into their private bedroom. They said, “I don’t really feel safe because of people coming in.”

Staff told us management and senior staff completed the care plans and risk assessments. They told us they could view people’s care plans on their handheld devices. One staff member told us, “I would share concerns with head of care/management.” Staff told us guidance from senior leaders in relation to risk was not always clear. One staff member shared, “In regard to the stair gates, we were given unclear and contradictory information from both the registered and support managers. As you can imagine we were very confused but seem to now have a clearer system in place to check them.”

Several call bells were found to be out of reach to people, a person was observed pulling at the floor sensor mat to grab the call bell which was on chest of drawers out of reach. A communal toilet had no call bell in place. People could not always call for help if they fell or needed support. Drinks on over the bed tables were found out of reach for some people. People were at increased risk of dehydration as they were unable to reach their drinks. There were profiling beds that had both a soft foam mattress and a full airflow mattress on the bed (some of these were overlays). This increased the risk to people especially with bedrails as it reduced the safety measurement from the top of the mattress to the top of the bedrails. At the time of inspection there were no monthly bedrail safety checks being completed by maintenance. Bed rail covers were not always on bedrails and some with covers still posed a risk of entrapment due to the full length of bedrails not being covered. Pressure mattresses were set at double the weight for some people. This would reduce their effectiveness at minimising the risk of pressure damage and may have increased the risk. Risk assessments described toiletries to be in locked away due to the risk of ingestion, however we found examples of this not happening, with toiletries and razors found in unlocked cupboards and accessible to people. Oil filled radiators were found in the dining room with trailing cables and no covers, presenting a risk of trips and burns.

There was an absence of risk assessment for people known to have specific conditions. For example, there was no risk assessment or care plan in place for a person with Asthma, and only generic information regarding another who experienced seizures. There was no detail providing guidance to staff on how the condition affected the individuals and how to manage the condition effectively. Risks arising from the use of equipment including profiling beds and bedrails had not been properly identified or mitigated. Bedrail risk assessments were tick boxes with the need to elaborate in the notes section, however the notes sections were blank. There were no monthly bedrail safety checks being completed by maintenance. Repositioning records indicated people were not being repositioned in the timeframe assessed as necessary. A person assessed as needing repositioning 2 hourly through the day and night has gaps in their chart of up to 5.5 hours. This put them at increased risk of developing pressure ulcers. Catheter care charts indicated several hours between drainage (up to 16 hours for 1 person) and there were gaps in recording urine output. This increases the risk to the people if an accurate measurement is not taken as the person maybe in retention. There was no evidence of bath water temperatures being taken as the record sheet was blank. This put people at increased risk of scalding. The failure to assess and mitigate risks to people was a breach of Regulation 12 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Some people did not have call bells in reach. This meant they were unable to summon assistance from staff if they needed it. Most people told us they were happy with their rooms. One person said, “I like being in my room, I’m happy with what I have.” Another said, “I’m as happy as I can be with my room”, adding they got a little bored of the same surroundings. A third person said they had an issue with people coming into their room. They told us they would like a lock on their door. We spoke with the registered manager who said the lock would be reinstated. A representative of the provider subsequently confirmed a lock had been installed.

Staff confirmed that they have not had fire evacuation drills. Drills are necessary to help staff understand what to do if fire breaks out. As staff did not have the required fire drill training, they may behave inappropriately if fire breaks out which increases the risk of a delayed or unsafe evacuation for people.

We observed gates on stairwells that were not fit for purpose. Some stair gates were mesh gates that had not been locked. This meant a person could lean into the panel that would give way. The manufacturer recommendation for these gates if for use with pets and babies/young children. There was an increased risk to people of either falling down or falling over the stair gates due to their height. Some stair gates were not securely fixed to the wall. Fire safety was not well managed and areas of the home had been left vulnerable. There were several cupboards and void areas within the home that did not have smoke detection. The lack of detection devices could mean staff would not be provided with an early warning if a fire were to start in one of these areas. We observed call bells were placed out of reach of some people and movement alert equipment installed to keep them and others safe was not being used as intended. Some cupboards which should be locked were found unlocked. The door to boiler room was unlocked with access to hot pipes. This put people at increased risk of burns. Equipment was stored in corridors on the ground floor and within the alcoves in hallways on the first and second floor. This hazard put people at increased risk of trips and falls. Cleaning trolleys were observed unattended and accessible to people. This put people at increased risk due to accessibility to chemicals.

We expressed concerns over stair safety on the first day of our visit, yet we found gates remained open or unlocked including on the third day we visited. Though a representative of the provider had advised staff would be assigned on each floor to monitor the gates until they were replaced, this was not effective. Actions identified in the provider’s fire risk assessment dated January 2024 noted 32 significant findings. Of these, 15 dated from the 2023 audit. Furthermore, a service report from the local fire and rescue service, dated February 2023, detailed improvements that had not been completed. Fire drills had not taken place in accordance with the provider's policy. This had been identified in fire risk assessments in January 2023 and January 2024 but not actioned. There were gaps in fire safety checks including for doors and emergency lighting. The monthly fire door check, last completed in March 2024, had not identified holes in doors - created to fit locks and bolts - as an issue (this would void the fire protection rating for the door). There was an increased the risk of fire spreading due to the ineffective doors that were in place. Monthly monitoring of equipment including bedrails, wheelchairs and fans were not being consistently checked and recorded. We identified issues with water temperature. Whilst checks had been undertaken, some temperatures were recorded above the recommended level. There was no record of this being addressed or the thermostatic mixer valves being adjusted. The provider’s Legionella risk assessment, dated October 2023, noted action from previous assessments as outstanding. A monthly check of water temperatures had entries placed in the wrong column. Incorrect recording increases the risk of Legionella bacteria growth. The failure to ensure the safety of the premises and equipment was a breach of Regulation 12 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People and relatives expressed mixed feedback on the staffing level. One relative said, “Staffing levels are not very good. There isn’t enough staff to make sure that all patients’ needs are dealt with as they should be. On several days I have seen very few staff” Another told us, “Often when visiting mum has had to wait between 15 and 30 minutes for the toilet which she gets very distressed about.” However, one person told us, “I get help when I need it, I don’t need to wait.”

Staff told us they were not always able to deliver care as they would wish due to time pressure. One staff member told us, “I just think there is not enough staff in general. Middle floor is the hardest one as we have a lot of residents there, many need two staff to do care.” Others said, “The ratio resident vs. staff should be a bit more so you can deliver proper care, comfortable care” and, “We are often short staffed.” Staff did not appear to have the expected knowledge on safeguarding, mental capacity and deprivation of liberty safeguards. There was limited understanding from staff regarding what training they had and hadn’t completed and limited understanding of incidents and learning.

On the first day of our visit, lunch was an hour delayed due to staff shortages in the kitchen. This resulted in people getting upset. We saw staff, including the activities lead and gardener, supporting people during the mealtime. On the fourth day we visited, we observed 3 people sitting in the dining room for most of the day, with limited interaction from staff other than at mealtimes. For people who chose or needed to be in their bedrooms, interactions appeared to be task based with little social or emotional engagement from staff.

We were not assured there were sufficient staff deployed to appropriately meet people’s needs, particularly their emotional and social needs. Records of activities and interaction indicated people, particularly those cared for in their rooms, received little to no social interaction for extended periods (20 days in the sample of records reviewed). We were not assured staff had the relevant training, competency and skill to meet people’s individual needs related to behaviours, nutrition, capacity and other aspects of care. The service’s training matrix showed significant shortfalls in training. Induction for new staff to the service did not appear robust. The registered manager confirmed training was not up to date and the Care Certificate for new starters was not fully completed for staff who started in 2022 (the expectation is to complete the Care Certificate within 3 months). There was no recorded training in relation to supporting people’s specific needs such as Epilepsy, Catheter care and Parkinson’s Disease. The failure to ensure staff received appropriate training to carry out their duties was a breach of Regulation 18 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Recruitment checks were not always carried out in line with the law. There was lack of schedule 3 checks for staff. The provider’s policy refers correctly to schedule 3 in relation to the requirement of obtaining satisfactory evidence of conduct and satisfactory verification of why employment ended. The failure to complete schedule 3 checks was a breach of Regulation 19 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Other recruitment checks, including DBS checks, references and checks on overseas workers had been completed.

People had concerns about the cleanliness and hygiene within the home. One person told us, “The dining room is not clean. Under the radiator has not been cleaned for weeks and often the chairs need a good clean.” Another said, “Cleanliness has improved slightly although I would like to see the cleanliness of the kitchen when next inspected go up as 3 [food hygiene rating] isn't very good.”

Several staff mentioned they had been without or low on housekeeping staff. One staff member said, “The home isn’t always necessarily the cleanest. I work at night so I get there in the evening and things like the floors and the chairs that you should keep up with cleaning throughout the day aren’t all that clean.” Another told us, “Sometimes your contact points, you can tell they haven’t been cleaned for far too long, like light switches, door handles, handrails. It has got better recently.”

The environment was visibly unclean in most areas. Poor cleanliness was observed throughout the home of furnishings, pressure cushions, floors, toilets, corridors and equipment. There were areas of the home that had visible dust on some surfaces and cobwebs at high points. Carpets were found to have stains and some carpets unvacuumed. Some equipment such as stand aids, wheelchairs and tilt and space chairs were dirty. Bath seats had a buildup of grime under the seat and areas of rust where the paint had come off. There were numerous hand sanitiser dispensers throughout the building however none of them had any hand sanitiser in them except for the staff toilets. There were several areas of the home that had extremely strong smells of urine.

We could not be assured systems to prevent and control infection were robust or effective. The cleaning schedules in place were not effective with records found to be incomplete or inconsistent. Staff training in infection prevent and control was out of date, with half of the staff team and most of the housekeeping staff overdue refresher training. Audits of the environment completed by the area manager in the first quarter of 2024 recorded, “Environment is clean, tidy and odour free”. We found significant issues with the cleanliness of the environment and equipment which demonstrated audits had been ineffective in driving improvement. The failure to assess, prevent, detect and control the spread of infections was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People and relatives highlighted issues with the support received to take their medicines. One person explained they hadn’t received one of their medicines since staff hadn’t obtained authorisation from the GP. Another reported a sample they had provided was not sent off and was found in the fridge after 6 days. This would have resulted in a delay in obtaining treatment. A relative said, “Medication is given at irregular times.”

Where people were prescribed medicines on a variable or 'when required' dose, staff were unable to show us guidance on how individuals should be supported. We could not be assured information was available to staff to guide their practice and ensure people received consistent support. This was of particular concern where people lacked capacity to request these medicines, for example pain relief. Staff were able to demonstrate how they identified and recorded creams administered as part of personal care, checking where and when to apply them. Staff administering creams were not aware of the body maps containing details of when and when to apply creams as part of personal care.

Some people had not received their medicines consistently due to them being out of stock or because staff had not escalated concerns when a person had refused or not received their medication. A review of electronic Medicines Administration Records (e-MAR) provided by the service indicated one resident did not receive a medicine as "stock unavailable". Two residents were not consistently administered their medicines as they were either "asleep" or "refused" and this did not appear to have been escalated. There was conflicting information in some care plans and risk assessments for people. For example, one person was noted as not being on any medication to assist with regular bowel motion, yet on another document it stated they were prescribed a medicine to help with this. Medicines including controlled drugs (CD) and those requiring refrigeration were stored securely. Whilst fridge & room temperature records were kept, records for one fridge indicated it had been outside of its recommended temperature range for over 4 months and no action had been taken. Whilst most medicines had the date opened and a revised expiry date, we saw a liquid CD medicine that had passed its in use expiry date and was available to be administered. Controlled drugs returns records were not always complete. Out of date patient information leaflets were available that had not been removed, although this had been identified by a previous external medicines audit. There were staff who are administering medicines who had not completed all of the required training or had out of date training. The training matrix showed staff completion of the provider’s mandatory eLearning in medicines was out of date for 8 senior staff. The failure to manage medicines safely was a breach of Regulation 12 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.