Blackthorns

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 assessed all 8 quality statements from this key question and found areas of concern. The scores for these areas rated this key question as requires improvement, which meant the rating of good given in our last inspection [Published March 2023] had not been maintained. We found a breach of legal regulation relating to how risks associated with people’s care were assessed. People’s risks were not always adequately assessed, managed, communicated or mitigated, which placed people at risk of potential harm. Staffing levels and staff deployment did not always safely meet people’s holistic needs and ensure staff could carry out their role effectively. The provider took action to increase the staffing levels following our feedback.

Prior to starting the assessment, we were aware of the ongoing visits and support being given from the local authority organisational safeguarding team (OST). Undertaken as part of investigating safeguarding concerns that they had received, and checking people’s safety and welfare. Although they noted improvements, and the provider had worked well with health and social care professionals to address issues, people remained at potential risk until all the changes had been made and embedded in practice. The service had systems to ensure staff were recruited safely, and people received their medicines as prescribed.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

One relative said," Sometimes I have to repeat the same things before they get done.” Most relatives we spoke with said they were unaware of the complaints policy. However, relatives told us they felt comfortable raising any safety issues directly with the management and felt it was generally acted on, except for the ongoing issue of missing laundry.

When visiting professionals reported people’s call buttons were out of reach and/or their sensor mat unplugged, staff acted immediately to ensure people’s safety; however, further learning was required when the same incidents was identified again during future visits.

A staff member told us, “After safeguarding visits, we have a team meeting, and they inform us what has happened. We talk about it. I find the feedback from management is good. We talk about not making the same mistakes again.”

The registered manager said ‘concerns and reflections’ were discussed in staff meetings. The team considered and developed lessons learned to raise awareness and drive improvements. However, despite this, there were incidents with similar themes reoccurring.

Processes were in place to listen to and act on feedback from people using the service and external agencies. However, some incidents reoccurred, this did not demonstrate that a safety culture was fully embedded in practice, and further improvements were required.

For example, although actioned during our first site visit, we found the provider’s summary list of people’s personal emergency evacuation plans (PEEPs) providing information for everyone who lived at the home was not up to date. The registered manager acted straight away to ensure it was updated. However, during the second visit, we found it had not been updated to reflect changes in occupancy. This meant the information given to emergency services would not be accurate in an emergency.

The quality of people’s experience when moving between their own home or hospital setting to Blackthorns varied. This was because it depended on the quality of their pre-admission assessment and having good communication systems in place. Where staff had not met the person and gained feedback directly from people who knew them well, they were reliant on what health and social care professionals had told them. This impacted on staff assessing the new person’s compatibility with people already living at Blackthorns. Also, it did not enable the person and their advocate to ask staff questions about the service and talk about their expectation, worries and needs.

Staff told us they were informed about new admissions during handovers and could access information about the person’s care and support needs via the handheld devices they carried on shift. However, the quality of the information would be limited to what they had learnt about the person during the pre-assessment. Some pre-assessments we saw were not sufficiently detailed.

The registered manager said they could feel pressured at times by external health professionals to admit people quickly. It was only after admission to Blackthorns that staff found people had environmental, physical and/or mental health needs they had not been made aware of. This impacted on the quality-of-care people received.

Social care professionals had raised concerns with management about the quality of their pre-assessments and had also told management not to feel pressured to take new admissions and to complete assessments in person. Although advised in June 2024, we saw this was still not always happening. This placed people at risk of receiving care which did not always meet their needs.

The provider told us they were currently reviewing their pre-assessment paperwork and aimed to conduct in-person assessments.

The service used a ‘Hospital’ pack recording system to share information when transferring a person to the hospital. This ensured that treating health professionals had information about the person’s needs, including what medicines they were prescribed.

People told us they generally had good relationships with most staff members, finding them to be friendly and approachable. They felt comfortable raising any concerns about staff conduct with management and believed their concerns would be addressed. However, we also identified instances where people felt uncomfortable reporting concerns, as they feared it would make them vulnerable. During the inspection, we identified information that required further investigation. Consequently, we made a safeguarding referral to the local authority, which was under investigation. The registered manager was cooperative and said they would act based on the investigation's outcomes. One person reported another person had entered their bedroom without permission and shouted at them to leave. Other people also reported similar incidents, including unauthorised access to their personal belongings. Although they tried to be understanding, given the service supported individuals living with dementia, they also expressed the need for their bedroom to be a safe and private space. A staff member confirmed these incidents did upset people. These situations potentially put people at risk of verbal or physical abuse.

The registered manager said they were reviewing the service's layout and usage to address the issue of people wandering into other people’s rooms. They were also taking steps to increase staffing levels, which would help in monitoring people's whereabouts and would help to reduce the risks of people accessing other people’s private space and belongings.

Staff received training in safeguarding people from abuse. They stated they would not hesitate to report concerns and were confident management would act on the information. A staff member said, "I would report to the care team leader. If they did not take any action, I would continue reporting up the management chain." They were aware of how to directly contact the local authority safeguarding team if needed.

During the site visits, we observed staff interactions with people. We saw staff treated people with kindness and respect. However, we also noticed inaccuracies in recording what a person had eaten, a concern that had been identified by the local authority safeguarding team as well. As part of monitoring to ensure people had enough to eat and drink, staff must maintain accurate information. When we brought this to the attention of the registered manager, they investigated and found that incorrect information had been recorded in that person's care records. They told us staff would receive additional training on record-keeping to minimise the risk of recurrence.

The provider had an accessible safeguarding policy for staff. Following concerns raised directly with the CQC in March 2024, the local authority organisational safeguarding team (OST) has been supporting the service through regular ongoing visits: 14 at the time of this assessment. These visits were carried out as part of safeguarding investigations, to check on people's welfare and safety and offering leadership advice to drive improvements. Reports indicated that leaders were responsive in working with the safeguarding team to make the necessary improvements. However, the reports also showed the oversight had not been effective enough, and the improvements had not been sustained. Following our feedback, further action was being taken to address this, including increased monitoring checks to ensure staff were following safe practice.

We found people’s experiences were influenced on how proactive and reactive the staff had been in identifying, communicating and mitigating risk. For example, some staff did not check that people had access to a call bell or sensor mat. This meant that people would be unable to call for assistance.

Staff told us they received training and felt confident identifying and managing risk. One staff member said the training included "Skin tear prevention, moving and handling, dysphagia training and fire prevention." Staff said people's risk assessments guided how to safely support someone, including which transfer aids to use. Leaders confirmed they reviewed the risk assessments to accommodate people’s changing needs. However, it was noted that risk assessment and monitoring of people's safety were not always effective. For example, the risk assessment for a person at high risk of falls did not provide staff with sufficient guidance on how support the person if they fell, including which transfer aids to use.

During our visits, we discovered the rubber ferrules (feet) of 2 people's walking frames were worn down, rendering them ineffective and increasing the risk of slipping or falling. Staff had not identified this issue, but the ferrules were promptly replaced once it was brought to management's attention. Additionally, we found while locked cupboards reduced the risk of people accessing hazardous cleaning products, one of the satellite kitchens was left unlocked. The cupboard was locked once we brought this to the attention of the manager.

Risks associated with people's care had not always been identified and /or acted on promptly. Where people's pre-admission risk assessments and ongoing reviews of their care have not been completed thoroughly, they had impacted people's safety and welfare. The risk assessment is a crucial part of a person’s care, as it allows the provider to ensure that they can meet the individual's needs, including providing necessary equipment. Failure to identify risks or gathering insufficient information negatively impacted people’s welfare and hindered the staff's ability to provide safe care and adhere to safety policies. For example, the absence of a suitable wheelchair for a person was not properly risk assessed, leading to staff using an unsuitable wheelchair. The OST reports reflected our findings where they had highlighted risks not identified by the provider's risk management process. While improvements had been noted, a health and safety culture must still be fully embedded to reduce the risk of potential harm.

People and their relatives praised the layout of the service and the homely environment. One relative told us, "It's light, airy and there's access to the garden." One person said they could smoke outside but not inside due to the fire risk. Another person, pointing to their walking frame, told us they had the equipment they needed to support their needs and promote their independence. However, feedback from relatives and visiting professionals showed that some people's experience could have been more positive. This was due to people being put at risk because equipment was not in place when they were admitted, a breakdown in communication, or a delay in providing/sourcing equipment as needs changed.

The leadership told us how they would use the feedback from external professionals as part of their ongoing commitment to drive improvements. This included ensuring they had any required equipment or acted to source it before accepting new admissions. Staff told us they received training in using transfer aids. A staff member told us, "With the hoist, we check the sling, check the hoist, does it look clean, is it working, check the battery." If they had any concerns, they would report them and only use the aid once it was fit for purpose.

As a specialist home for people living with dementia, we found a lack of specific environmental aids to support this. Where people living with dementia were walking around or sitting quietly staring ahead in one of the small seating areas, there was a lack of points of interest, and tactile objects to provide mind and sensory stimulation.

There was a new vacant 3-bedroom Warren Suite, decorated to a high standard. The registered manager told us the unit would be used for semi-self-caring/more independent people.

The provider had audits and checks in place to ensure equipment used by people and staff was fit for purpose. However, until we brought it to the management's attention, this did not include checking people's walking frames for worn rubber ferrules.

Records showed regular equipment servicing, including fire alarm testing and checking mobility equipment.

As part of safety arrangements, the front door was locked, and visitors rang the bell to gain entry. However, following 2 separate issues where people, although they had not come to harm, could not be located, the provider was looking to have CCTV installed at every entrance and exit to support staff in identifying if the person had actually left the service and, if they had, when and how.

People praised the hard-working staff and felt their needs were being met, but most people that we spoke with felt the service needed more staff. They told us how staff were very busy, which could impact on them waiting for their meal, in answering call bells, or providing social interaction.

Family members who spoke on behalf of people told us they had confidence in the staff's ability but provided mixed feedback regarding staffing levels. One relative told us staff did an, "Amazing job." Another commented, "There is always someone [staff] popping in and checking on" their family member's welfare. However, most felt staffing levels needed to be improved, especially at weekends, to ensure there were consistently enough staff around. They felt staff did their best, but as 3 relatives commented, staff seemed to be, "Rushed off their feet," which had also, at times, been noted by visiting professionals. Two relatives told us how they had provided personal care during their visit. Another commented, "There does not appear to be enough supervision with [family member] eating and drinking."

Feedback from the staff reflected what people, relatives, and professionals told us. Improvements were needed to ensure enough care, domestic, and catering staff. A staff member told us, "The less staff, the slower the process for residents. We're trying to beat time… mostly just speaking when doing things for people… not having time to sit and chat." Some staff felt they could manage if they worked with an experienced team who communicated and worked well together. During the feedback, senior management told us they would address the concerns by increasing the care, domestic, and kitchen staff coverage.

Staff told us they received a mix of face-to-face and e-Learning training to support them in their roles and keep their knowledge updated. A staff member said, "The training is good. There's a lot of new things to learn. There's continuous training, and if I have any doubts about how to do something or request more training, they will provide that."

We observed care staff were busy responding to people's call bells in a timely manner and worked hard to complete personal care tasks listed on their portable handsets. We saw some good interactions where staff checked with people to see if they were comfortable. The new deputy manager was working supernumerary and providing extra 'hands-on' support. However, despite the additional support, the deployment of staff meant there was only sometimes cover in communal areas, including the small downstairs unit. When staff were not around, vulnerable people who could not use the call system relied on others ringing for them. A communication breakdown meant 2 people were still waiting for their lunch while others were offered dessert. We observed how the impact of insufficient catering and domestic cover had caused delayed meals and shortfalls in the cleanliness of the service.

The provider used a staffing tool to calculate their staffing levels. Although this provided a baseline to work from, it failed to identify where staffing levels and skill mix were not sufficient to meet the needs of all people using the service. This had a significant impact at times on the staff's ability to carry out their role to the best of their ability and provide safe, person-centred care.

The provider was receptive to our feedback and said they would take action to address our concerns, which included increased care and kitchen cover during the day. They would only admit new people with "low needs" until they had addressed the staffing situation. Staff were recruited safely, and all pre-employment checks were in place. The service used agency staff to cover shortfalls; where agency staff were used, they received an induction.

People, their relatives, and visitors praised the cleanliness of the service. One relative said, "It is very clean, and I was very impressed when I first went in there." Another said, "There is never any unpleasant smells when I have visited." However, 3 visitors commented about malodours, which were only sometimes addressed in a timely manner. One person said staff helped them keep their bedroom clean and tidy, "Cleaner empties bin every day," whilst also observing they were, "Short of staff lately."

Staff told us they had received infection control training, which included instructions on when to use personal protective equipment (PPE) to ensure people's safety. They said they had access to adequate supplies of PPE.

Where there was no domestic cover, staff told us it impacted their ability to clean the service thoroughly. One staff member said domestic cover had, "Never been this low." Another told us, "Big issue is covering the kitchen…weekend takes us off the floor to cover kitchen."

Leaders told us they would address staff concerns to ensure sufficient domestic cover, recruit more kitchen staff, and use agency staff if needed.

The general appearance of the service reflected what people told us, with areas looking clean and homely. However, closer observation reflected what staff were telling us, that although they were working hard, there were shortfalls in the cleanliness of the service. For example, we identified some bedrooms and shared areas where minimal cleaning had taken place due to time restraints. We found debris under chair seats and the bed, build-up of dust in the radiator covers, dirty cleaning trolleys, and in the sluice, sticky shelves where liquids had overflowed. We alerted staff when we saw an empty hand sanitizer dispenser, who immediately replaced it.

During lunchtime, we saw good practice with people being offered hand wipes to clean/refresh their hands. While assisting people with their meals, care staff wore a clean cloth or disposable apron as a protective barrier between their uniform and the food. However, a staff member was seen in the main kitchen without one. We saw this was quickly picked up by kitchen staff, as the staff member came out and donned a plastic apron before re-entering. However, per the provider's infection control policy, this was done without washing or sanitizing their hands.

Staff received training and Infection control, and audits were carried out to check the cleanliness of the premises. However, we found improvements were needed in monitoring the cleanliness and infection control standards.

People told us they received their medicines as prescribed and did not share any concerns about the management of medicines. One person said, “No problem, staff bring them around.” When people’s relatives observed medicines being given, they felt it was carried out in a safe manner. One relative told us they found staff administering medicines were,” Always patient.” Another said where prior to admission they had concerns their family member was not taking their medicine, since moving in, “I have no concerns.”

Visiting professionals provided examples where the service did not have a homely remedies policy in place, this could impact on people accessing medicines to support their well-being when needed. Homely remedies are specific medicines bought without a prescription, such as paracetamol; authorised by the person’s GP to be used if needed. This especially benefits people who may develop pain symptoms ‘out of hours’ for minor ailments.

Staff administering medicines told us they had received sufficient training to carry out their role competently and could tell what medicines people were taking and why.

Staff administering medicines wore 'Do not Disturb' tabards to reduce the risk of interruptions and mistakes. We saw staff behave calmly, checking to ensure people had a drink to assist them in swallowing their medicines. People's medicine administration record (MAR) charts included a medication profile, which provided information on how they like to take their medicines and known allergies.

Where people were taking 'As needed medicines', referred to as PRN, we found some required more personalisation and staff guidance. For example, a person was prescribed PRN diazepam 'to be given no more than 3 doses in 24 hours.' Although the person had not been taking the maximum dose, there was no guidance for staff regarding the safe interval between doses to reduce the risk of over-sedation. Although staff could tell us what action they would take if PRN medicine to relieve angina or breathing problems did not work, this was not reflected on the PRN forms.

The registered manager acted on our feedback by implementing systems to review people's PRN protocols to ensure they were all in place and providing staff with clear, person-centred guidance. Managers carried out competency checks and monthly medicines audits to ensure staff were following safe practices and take any necessary action, such as disciplinary action, extra training, and supervision. Although the provider had a homely remedies policy, it had not been implemented at Blackthorns as there were no homely remedies stocked at the time of inspection. This system's lack of implementation could delay people's access to medicines to support minor ailments.