Archived: Bloomsbury House

On this page

• 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

The service’s effective rating has improved since our last inspection and is now requires improvement, meaning further improvements are still required. Care was not always being delivered in line with best practice. At this assessment we found there was a continued breach of regulation relating to consent. Records to demonstrate compliance with the Mental Capacity Act 2005 were not consistently decision specific and were generic.

People’s needs were not being consistently assessed as these changed. People and their relatives were not always involved in assessments relating to their care, meaning their contributions could be missed.

People were supported to access healthcare when required. However, staff failed to consistently follow healthcare professionals’ guidance. This included making sure people were encouraged to use equipment brought for them to mitigate the risk of further skin damage.

The monitoring of people’s nutritional and dietary needs had improved. However, monitoring people’s hydration needed improvement. Recording in care plans, risk assessments and daily notes was inconsistent. Staff had not always received the appropriate training to support them in their role.

Some work had been undertaken to improve signage around the service to help those living with dementia navigate themselves around the home.

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.

Some people could not recall if they had been involved in assessing their needs. Relatives told us they were aware of their family member’s care plan but could not always recall being involved in the re-assessment of care needs and support. One relative told us, “I’m very happy with the support given to [person]. They (staff) will always ring me to keep me informed of any changes or appointments."

The registered manager told us they would complete an assessment for any new people moving into the service.

Staff told us they knew people well because they were an established team. They told us people’s support needs were updated and reviewed regularly. The registered manager and a non-care staff member reviewed people’s care needs on a monthly basis. However, discussions had with staff identified there was not always a consistent approach to supporting people to meet their needs. For example, when people had a fall or needed support to get out of bed.

Effective systems were not in place to ensure people’s needs were consistently and effectively assessed and reviewed when changes in health and wellbeing occurred. For example, we found that care plans did not contain clear guidance for staff to follow to enable them to support people when they were emotionally distressed. Episodes of emotional distress did not prompt staff or the registered manager to review people’s needs in relation to this aspect of their care. Most people living at the service were living with a dementia related condition. The care plans lacked detail of how people should be supported with their wellbeing when they became anxious or upset. For example, 1 person’s care plan recorded the person’s health condition was Alzheimer’s Dementia followed with, recorded under the heading ‘treatment, objectives, outcomes’ direction for staff to ‘reassure [person] if they get confused or forgetful. Their care plan did not provide guidance for staff on how to support them on those occasions and what to do if they were to present in a confused state.

Effective systems were not in place to ensure people’s needs were consistently and effectively assessed and reviewed in the event of head injuries sustained following a fall. There was no policy or individual care plans for staff to follow in relation to head injuries. The provider introduced a policy at the time of our assessment. The policy was not sufficiently detailed or accurate to support staff to respond consistently to ensure people would have their needs met in a timely and effective manner.

People and their relatives raised no concerns around how their care and treatment was delivered.

People we spoke with could not recall if they had been involved in their care planning.

Relatives we spoke with said they were able to contact the home to get information and advice around their loved one’s care needs.

Staff lacked knowledge of how to support people living with dementia. One staff member told us they could not recall if they had completed any training for dementia. Given the majority of people at the service lived with some form of dementia, this meant they were being supported by staff who did not fully understand their specific needs.

Staff were also unable to tell us how they applied best practice guidance around skin care and repositioning, including when supporting people who were at risk of developing sore skin. Staff failure to record repositioning movements and support people with additional equipment provided by community nurses had the potential to put people at risk of avoidable harm. One staff member told us they did not use forms to record when people were repositioned. The registered manager told us, “People reposition themselves.” However, it was not recorded in the relevant people’s care plans that they were able to reposition themselves and both people were at high risk of pressure damage to their skin.

At the time of the assessment, 1 person at high risk of developing pressure damage to their skin had no effective monitoring process in place, such as the use of the Waterlow score. The Waterlow Score is a widely used risk assessment tool which plays a vital role in identifying and managing pressure ulcer risk and is a crucial aspect of a person’s care. The service did have a pressure sore risk assessment that had been ‘scored’ by an administrative staff member who had not completed any relevant training relating to pressure care management. According to the provider’s own training information only 6 care staff out of 18 had completed this training.

Community nurses were attending to people living at the service to monitor their skin condition. Clinical tools based on best practice were used. For example, the Malnutrition Universal Screening Tool (MUST) was used to identify people who were at risk of malnutrition. When people were losing weight, plans were put in place to support with this.

Relatives said they were kept updated about their loved ones’ changing health needs.

The registered manager and staff told us they would contact the GP when a person was unwell.

External professionals told us they had a good working relationship with staff and leaders at the home.

On reviewing care records and incident accident forms, we found staff were not consistently following an agreed course of action to ensure a consistent approach to managing people’s health needs. For example, for 1 person the staff approach was inconsistent when contacting the emergency care team in the event of the person having multiple unwitnessed falls. One manual handling plan instructed staff to contact the emergency team and make the person comfortable until the team arrive. However, incident forms did not always reflect this instruction was followed. The incident forms had not been robustly reviewed, this meant provider audits had not identified staff were not following the agreed plan, in the person’s manual handling plan, to manage this person’s support needs to mitigate risk.

It had been clearly documented in 1 person’s care plan by a visiting health professional staff were to encourage the person to wear pressure relief boots to support the person’s feet to mitigate the risk of skin damage. However, on reviewing daily records, our observations and conversations with staff we found the advice in the person’s care was not being followed by staff.

Handover meetings were taking place and there was a handover book for staff to write up notes to share with staff coming on duty.

We saw records of staff contacting the GP and speaking with visiting community nurses in relation to people’s health needs.

People and relatives told us health care professionals were involved when required, including the GP, community nursing team, hairdresser, podiatrist and opticians. One relative said, “[Person] gets their hair done now and they never bothered with that before. It’s been years since they looked as good as they do now. They’ve (staff) tuned in to what makes [person] tick."

Staff said when people were unwell, they would speak to the registered manager or senior care staff and contact a health care professional. However, when staff were asked about the use of equipment to reduce the risk of further skin damage, recommended by a health professional, we were told the equipment was not used. This meant that while staff were aware of the risk to the person’s skin, they were not encouraging the use of this piece of equipment to prevent further potential skin deterioration.

We found there was some documentation in people’s care plans on specific conditions such as chronic kidney disease. However, the information contained within this documentation was limited and gave no direction for staff on what symptoms to look out for, other than to contact the GP with any concerns. For example, under the section headed ‘Treatment, objectives and outcomes, the information for staff on chronic kidney disease advised them to ‘Contact GP of any concerns GP to arrange regular blood tests.’ There was no additional information to help staff identify symptoms that could indicate a worsening in this condition or how often the GP should be contacted to arrange regular blood tests. There was no information for staff to aid their understanding of the impact this condition could have on the person.

People were supported with other health care needs including dental, opticians and podiatry appointments.

People shared no concerns with us concerning how their care was monitored and improved. One person told us, “I am weighed every week, the staff told me they just need to keep an eye on it (weight).” Another person told us the service would arrange for a doctor to visit if they felt unwell.

The registered manager told us they monitored people’s fluid and nutritional intake, oral health care and falls. However, this approach to monitoring, for example, people’s fluid intake had not considered people’s individual weights which impact on the required daily intake to maintain effective hydration.

Staff told us how they would monitor people’s care to make sure people’s needs were met. However, when people, living with a form of dementia, had become distressed or anxious, for example during personal care, the staff response to how they supported the person was to leave the person alone until they ‘calmed down’. This approach did not demonstrate how it benefitted the person in a positive way.

The provider did not have effective systems in place to consistently monitor and improve people’s outcomes.

The provider failed to ensure that staff understood how to support people living with dementia when they experienced high levels of anxiety, particularly during personal care. People’s lived experiences and their distress was not monitored in order to develop effective strategies to help keep them calm and reduce their distress. We noted from people’s care plans and incident records that no action had been taken to monitor this to determine why a person’s anxiety may have increased, and, if medication was administered, whether this was the best method of reducing the anxiety.

People's nutritional needs were being met and relevant healthcare professionals, such as dieticians had been involved. However, we found the service was using a generic process to monitor fluid intake for people which had not considered people’s different weights. This meant we could not be assured people had been drinking enough fluids that could impact on their skin integrity and increase the risk of urinary tract infections. The registered manager responded to our feedback in relation to this and introduced a new process and form for staff to complete. This form took account of people’s individual weights and more accurately recorded the suggested safe hydration intake for that person each day to maintain their health.

We found examples of medical assistance and support being sought in response to changes in people’s needs and outcomes in a timely way.

People and relatives gave us positive feedback about staff seeking consent before completing any care or support. However, our observations showed people’s consent was not always gained before care and treatment were delivered. During our assessment, the registered manager was seen to knock on a bedroom door, but they did not wait for consent to enter the room and opened the door immediately. There was a staff member with a person conducting personal care support. The staff member had to call out to the registered manager, “I’m giving personal care.” At this point, the registered manager closed the door.

We also observed a staff member putting gloves and eye masks onto 2 people who were sleeping in the communal lounge. As they were asleep, they were unable to consent to this at that time.

Most staff were able to tell us how they provided care in line with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). However, not all staff were able to demonstrate their understanding of the MCA and DoLS.

Effective systems were not in place to ensure the requirements of the MCA and DoLS were consistently followed. DoLS applications had been submitted for every person living at the service. From discussions with the registered manager, it was clear this had been implemented as a blanket approach and the registered manager had not considered individuals’ mental capacity to make informed decisions about the care, support and living at the service.

The registered manager did not have a good understanding of the requirements of the MCA or how these applied to people living at the service who were under a DoLS. We found mental capacity assessments had not been consistently completed on a specific decision basis.

There was a lack of evidence in some care plans around how people engaged in their assessment reviews, how information was provided or what adjustments were made, and what the person’s views were. Where it had been deemed the person lacked capacity, there was not always evidence of a best interest decision to determine the least restrictive support and care options.