Blakesley House Nursing Home

On this page

• 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 identified breaches of 3 regulations relating to safe care and treatment, premises and equipment and staffing. The arrangements for staffing meant that sometimes staff were working excessively long hours without a break. This practice placed people at risk. Some risks within the environment had not been properly assessed and planned for. Staff did not always know how to respond in the event of a fire and needed more guidance and support in this area. Medicines were not always managed in a safe way. The provider had made improvements to the way individual accidents and incidents were investigated. However, further analysis of these was needed to ensure lessons were always learnt. People felt safe at the service. The staff had undertaken safeguarding training, but they needed more guidance to understand how to report abuse. There were systems to help make sure people had safe transitions between services.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People did not have any concerns about the way in which the staff learnt from incidents and accidents.

Most staff told us they discussed incidents, accidents and things that went wrong when they had been involved with this. They told us the manager helped them learn from these. However, some staff explained the handover of information between shifts needed to be improved. They said that they did not always have the right information about problems that had happened when they had not been at work and so they could learn from these.

The way in which accidents were monitored and recorded had improved. However, a recent visit from the local authority commissioners identified not all accidents were properly recorded, reported and responded to. During our assessment, we looked at records relating to accidents and incidents. In some cases, there was evidence of investigations into these and learning to help prevent reoccurrence. However, some records did not show if investigations had taken place. We spoke with the manager about this. We also found that whilst there were some records for the investigations into individual incidents and accidents, there were no systems to enable staff and the manager to have an overview of themes and look at how to implement learning across the whole service. We also discussed this with the manager so they could improve their systems and processes in this respect.

People using the service were supported through the provider's joint working with other professionals. People told us they were supported to access appointments. One person explained they visited the home for short stays and that the transition between their permanent home and Blakesley House Nursing Home was positive.

Staff told us they supported people to access healthcare appointments.

The local authority had carried out monitoring visits to the service. Following the most recent visit (April 2024) they stated that improvements had been made to the pre-admission process and when people were discharged from hospital. They explained that the provider had made contact with GP’s regarding people when they moved to the home. However, they also found that the provider had not always notified all relevant parties about transitions, for example when a person was admitted to hospital. They had reminded the provider about the need to do this.

The provider had processes for making referrals to external professionals when people first moved to the service. We saw that people had been supported to access the services they needed.

People told us they felt safe at the service.

Some of the staff we spoke with did not demonstrate a good understanding of safeguarding processes and who to speak with if they had safeguarding concerns. These staff were not able to tell us about external agencies, such as the local safeguarding authority, CQC or the police, who they may need to inform if they had concerns about the safety of people using the service.

The staff supported people in a safe way.

The provider had not ensured staff were familiar and confident with the safeguarding processes. However, the provider had made improvements since the last inspection to how they investigated and responded to potential abuse.

People told us they felt risks were managed.

Staff did not always demonstrate a good knowledge of how to keep people safe in the event of a fire or emergency. Not all staff could describe the fire evacuation procedures or how to use equipment to safely support people to move.

We observed people were supported safely during our visit. Staff supported people who needed assistance to move and with eating and drinking.

The provider has an emergency kit designed to be easily accessed and used in the event of an emergency, such as a fire. None of the staff on duty could locate this equipment. This was only found when a staff member who was not on duty was telephoned and returned to the service to locate this. Recorded checks on this equipment last took place in 2022. Failure for staff to know the right procedures and how to locate essential equipment placed people at risk. The risks within the environment, including broken equipment, had not always been assessed. We observed a falling risk from a first-floor full length window. There was a railing designed to help prevent falls. However, the risks of people climbing over this had not been assessed. The door to this room was open and some people were able to walk unsupervised around the home. The assessment of this window must include the risks for all people who could potentially access this. The lift at the service had broken down in April 2024. This meant some people were not able to move between floors. Other people accessed the stairs, some independently. The provider had carried out some assessments in relation to this. But these assessments did not always include comprehensive plans for mitigating risks. For example, people using the stairs independently and people being restricted because they were confined to 1 area of the home.

People felt some improvements could be made to the environment. One person told us they could not reach the call bell in their room because of where it was positioned. Another person told us that the showers could feel quite cold, so they tended not to use them.

Some staff told us that problems with the environment meant that people did not always have a good experience. One staff member commented, ''None of the baths are working and only 1 shower works properly because the water is not constant in the other shower.'' We discussed this with the manager who told us they were not aware of any problems with the showers but would look into this. Following our site visit, the provider had arranged for these to be checked. They reported the showers were in working order. Staff told us that there was a negative impact because the lift had been out of order since April 2024. They told us that 1 person in particular enjoyed socialising in the lounge but could not access the stairs, so they had been isolated in their bedroom. The provider had made arrangements to have the lift repaired.

Some areas of the environment needed improvements. We saw that some furniture had been damaged. This included chairs with torn coverings and tables where the veneer was peeling off. There was also a hoist which was out of order and stored in a person's bedroom. The provider offered shared rooms for people who wanted this. At the time of our assessment, all rooms were being occupied by 1 person. However, the additional beds had not been removed from some rooms to help create a personalised environment. Some communal rooms were difficult to access. The door to the conservatory, which also doubled up as a dining room was very hard to open and close. Some chairs in this room were hard to access because the room was cluttered. People were not offered the opportunity to sit at the dining table and lunch was served to people in the chairs they were sitting in the lounge or in their bedrooms. This meant they were not given the opportunity to move to a different room to eat. Two windows on the first floor were broken, exposing damaged woodwork and glass. These had been secured in a way which meant they could neither shut or open further. The manager told us these were due to be repaired and provided information about this for us.

Audits of the environment had not identified some areas of concern and therefore it was unclear if there were plans to repair these. Whilst the manager told us that processes were in place to make repairs; these were not always recorded. Since our last inspection, the provider had equipped and repaired restricting devices on most windows. People had the pressure relieving equipment they needed, such as mattresses. Staff understood how to ensure these were correctly set.

People told us they were happy with the staff and felt there was enough of them around.

Staff told us that they, and other staff, sometimes worked for 24 hours at a time. Some staff also told us they did not always have clear information to help them in their roles. However, most staff told us they had regular training and they felt supported. Nurses explained they were supported to refresh their clinical skills. The manager had arranged for some recent training to support staff to understand more about dementia. Staff told us this had been useful.

During our visit we saw staff were available when people needed them. They were attentive.

The staffing arrangements at the service meant that there were regular times when staff worked 24 waking hours at the service. On one occasion in July 2024, we saw a member of staff had worked for a continuous 48 hour period without any recorded time off. For 24 hours of this time, another member of staff on duty had also worked for 24 continuous hours. This practice increases the risk to people's wellbeing and safety. Staff working for this amount of time without breaks and sleep cannot safely provide the care for people. We told the manager this practice must stop. This is a breach of legal requirements for employers and best practice guidance including that from the Royal College of Nursing who state, ''We believe that no shift should be longer than 12 hours, and that a 12-hour shift may not be appropriate for all nurses.'' The majority of staff working at the service had been employed for some time and the staff team was stable. We saw recruitment checks had taken place when they were employed. However, we noted that the record for 1 member of staff showed their work permit had expired. We discussed this with the manager who told us they thought this had been renewed. The provider must obtain evidence of this. The provider should also follow processes to help monitor when permits and other documents are due to expire so they can obtain updated information when needed. Staff told us they had individual and team meetings with the manager to discuss their work. There was evidence of this.

People told us they thought their rooms were kept clean. They did not have concerns.

Staff told us they had undertaking training around infection prevention and control. They told us they had enough supplies of personal protective equipment (PPE).

We identified some areas of the environment and practice which increased the risk of infection. For example, non-catering staff regularly entered the kitchen without any PPE and without taking other steps to ensure cleanliness (for example washing hands). There were areas of the building and equipment which needed cleaning. For example, taps, showers, handwash basins and baths needed limescale removal, there were areas of high and low dusting which needed attention, and some of the fabric on furniture had been damaged increasing a risk of cross infection. Some food in open packaging had not been labelled with the date of opening. However, we also saw other areas of the building had been cleaned. People were provided with clean laundry and bedding.

The processes for monitoring and improving the cleanliness and mitigating infection control risks were not always being followed. Audits had not identified where improvements were needed. Good food hygiene practices in care homes require staff to test the temperature of cooked food before serving this. Records showed that only one food product had been temperature checked each day and this did not include all hot food. The chef explained that some cooked food was saved to be reheated later each day. There were no records to show the temperature of this had been reheated.

People told us they were happy with their medicines support. However, we saw that some equipment used for handling medicines had not been cleaned. The staff were polite, gained consent, and recorded the administration of medicines on the paper medicines administration record (MAR).

The staff told us they received training and were competency assessed to handle medicines safely. However, we did not see evidence of training being completed. Staff and leaders were unable to demonstrate when people had had their last medicines review or when they were next due. Staff were able to describe how and when to report a medicines incident. Staff were able to describe about the medicines people were prescribed and when to administer these. They also explained how they would raise concerns about people's medicines and healthcare conditions with their GP.

Not all medicines records, including topical medicine administration records, had been completed in line with national guidance. Medicines including controlled drugs were not stored in line with national guidance. We saw instances of medicine being stored in unsecured cupboards and out of date medicines not being segregated from stock in use. We found some medicines had expired. This placed people at risk of receiving medicines which were not safe to use. Controlled drugs were not destroyed in line with best practice. The service had a process for ordering medicines. The service worked with the GP and the local pharmacy to ensure people's medicines arrived on time. There was a system in place to which would allow staff to follow up on receiving medicines prescribed mid-cycle.