Blackwater Mill Residential Home

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• 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 assessed 4 quality statements within this key question. We found 2 breaches of the legal regulations in relation to good governance and notification of other incidents. The breach relating to good governance was a continued breach of regulation. There was a lack of evidence of a positive learning and improvement culture. The provider has conditions on their registration to send us an updated monthly service improvement plan. Some of the actions on the plan were recorded as met, however we continued to find concerns. Whilst staff told us they were happy with their jobs, some raised concerns around the inadequate support from some leaders including very poor practical assistance and emotional support. Staff and people were concerned by the recent changes in management at the service. We found gaps in governance and oversight which resulted in risks either not being identified or not being addressed in a timely manner. This placed people at risk of harm. The service had failed to notify the Commission of specified incidents that occurred in the service.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff reported concerns over their treatment from some senior leaders. They told us they could be confrontational, including with visiting professionals. One staff member said, “We have [a management team member] who is a little complacent in her role, argues with professionals and is slightly less experienced”. They added, “After CQC left, staff were shouted at by [a management team member] who told them they were at risk of losing their jobs and they would easily be replaced by new people who had applied for positions in the home. Some staff were visibly upset. I believe this was very unfair and belittling to the staff who in my opinion work extremely hard in a difficult and very busy environment”. Another staff member told us, “You can’t speak to people like that. Even when something is not your fault you get the full force of her having a go. I won’t be spoken to like that.” Whilst staff told us they were happy with their jobs, some raised concerns around the inadequate support from some leaders including very poor practical assistance and emotional support. One staff member said, “New starters appear to feel overwhelmed or are left to 'sink or swim' and then they soon leave.” Some staff told us they felt overwhelmed with the increasing demands on them. From the feedback we received there appears to be a blame and poor Organisational culture from some of the management team. However, we received positive feedback about other senior leaders, for example a staff member said, [Management team member] is wonderful, I can speak to her. Anything I go to her about, she will sort it.”

There was a lack of evidence around a positive learning and improvement culture. The provider has conditions on their registration to send an updated monthly service improvement plan. Some of the actions on the plan were recorded as met, however we continued to find concerns. The provider did not create an environment where staff felt they could raise concerns and that those concerns would be addressed. Staff feedback was not always sought or acted upon to improve the quality and safety of the service.

There had been staff turnover, including of managers leading to inconsistency in leadership. One staff member said, “We have had quite a few managers come and go in quite a short space of time and I do worry about that. We don’t seem to get managers for very long.” A relative said, “There is a big change in staff.” Staff and professionals reported challenges in working with some senior members of the team. A staff member told us, “You can’t speak to people like that. Even when something is not your fault you get the full force of her having a go. I won’t be spoken to like that.” A visiting professional said, “The attitude of the senior staff is confrontational, and it appears they do not understand the role of various agencies in providing care support or are unwilling to follow proper process.” Another shared, “I feel you cannot believe what they say as they are inconsistent with their reporting.” However, we received positive feedback about other senior leaders, for example a staff member said, [Management team member] is wonderful, I can speak to her. Anything I go to her about, she will sort it.”

At the time of our visit a recently registered manager left the service. A representative of the provider explained managers had left the post for reasons outside of anyone’s control. They told us they and other representatives of the provider were supporting the service in the interim. The senior team included a deputy manager was in post and two heads of care. The outgoing manager had been developing 1:1 supervision sessions with staff to enable a more positive culture of learning and to develop and to be able to tailor staff training plans to their specific learning needs. This was had not yet been embedded and the manager left employment with the provider after 8 days of being registered. There was no evidence of supervision records to refer to.

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.

Staff shared concerns regarding the turnover of managers at the service. One staff member said, “We don’t seem to get managers for very long.” At the time of our visit a recently registered manager left the service. A representative of the provider explained that some registered managers had left the post for reasons outside of anyone’s control. They told us they and other representatives of the provider were supporting the service in the interim. Staff told us guidance from senior leaders 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. We were told the gates could stay open during the day and then all be shut at night. We did this. We were then all hauled over the hot coals by the manager who denied saying this! As you can imagine we were very confused but seem to now have a clearer system in place to check them.”

The provider did not have effective systems in place to assess monitor and improve the quality and safety of the service. We identified concerns in the management and mitigation of risk. This included ensuring people received food and fluids of a consistency they could safely manage, promoting skin integrity via regular repositioning and the correct use of equipment such as pressure relieving mattresses. People’s care records contained gaps and inconsistencies. Planned maintenance checks on the call bell system, wheelchair visual checks and portable appliance testing (PAT) had not been completed according to schedule. This placed people at risk of harm. The provider did not operate effective systems to assess, monitor and mitigate risk. Risks relating to the stairwells had not been properly assessed or mitigated. Whilst temporary stairgates had been installed there was a lack of clear guidance to staff on how to use them safely. The fire risk assessment in place had not considered the addition of stair gates in relation to an evacuation of the building. This placed people at risk of harm. Following our visit, the provider worked with the fire service and an external contractor to redesign the safety of the stairwells. During this assessment, we identified 9 breaches of regulation. Two breaches are continued breaches, insufficiently addressed at our last 3 inspections. The provider’s systems had not enabled them to make and sustain improvement or to identify they were not meeting the requirements. This was a continued breach of Regulation 17 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to notify CQC of incidents in line with their legal responsibilities. We identified incidents including serious injuries and physical assaults that had not been shared with us. This was a breach of Regulation 18 Care Quality Commission (Registration) Regulations 2009 (Part 4).

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.

Staff had not received clear guidance in relation to mitigating known risks. One staff member shared, “In regard to the stair gates, we were given unclear and contradictory information from both the registered and support managers. We were told the gates could stay open during the day and then all be shut at night. We did this. We were then all hauled over the hot coals by the manager who denied saying this! As you can imagine we were very confused but seem to now have a clearer system in place to check them.”

We were not assured the provider had adequate measures in place to assess, monitor and mitigate the risk to people’s health, safety and welfare. The provider had failed to respond sufficiently to previous incidents of harm to learn and mitigate risk within the service. This has been documented within learning culture under the safe key question. The provider had failed to act on issues they themselves had identified. Monthly reports by the area manager did not demonstrate sufficient progress or sustained improvement on issues identified or actions set out. Support to people with personal care was noted as ‘appears to be getting worse’ with no baths or showers documented as being offered or having taken place. Gaps in records for topical creams, mattress and bedrail checks persisted according to the reports and there was a lack of progress with updates/reviews to care plans. In other audits we noted contradictory information and issues persisting over several months. For example, in the laundry audit, a training gap was identified one month, marked resolved the next and identified again in the third. This showed a lack of clear oversight and coordinated action. The provider had failed to respond fully to feedback. There was a lack of evidence to indicate learning from breaches identified during earlier inspections. Recommendations from partners including the local authority (June 2023) and Health Watch (February 2024) had not been actioned in full. Advice and feedback from the specialist Dementia Outreach Team regarding the care and support of a person living at the home had not been adopted, resulting in the person and others being placed at risk.