Archived: Bloomsbury House

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

The service was not safe and remained inadequate. At this assessment we found there was a continued breach of regulation relating to safe care and treatment.

People were at risk of not receiving safe care because care plans and risk assessments were not always in place, or updated, for specific health conditions and medication.

Incidents and accidents had not been analysed robustly to identify trends and no actions were put in place to mitigate future reoccurrence.

Staff had not always received the appropriate training, or guidance made available to them, in order to mitigate the risk of people developing sore skin.

There were concerns about the safety of people and staff should they need to be evacuated from the building, in the event of a fire emergency.

However, overall, staff had been safely recruited and there were enough staff available to support people.

There were safeguarding procedures in place and the home was clean.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People spoken with did not raise any concerns with us regarding the safety of the home. All those spoken with were happy with their care and felt the provider would listen to them and act promptly should they raise any concerns.

The Nominated Individual told us they used the last inspection to improve their learning and said, “We have grown [over the years] and had a few hic-cups along the way and we have learnt big time.” The registered manager told us they had implemented a process so that all incidents and accidents should be recorded. We were told the registered manager would review and analyse the completed forms and record actions taken and share any learning. This was not our finding during this assessment.

We raised our concerns regarding the review of risk assessments and care plans with the management team (the registered manager and nominated individual). They recognised further work was needed on these, although a period of 10 months had elapsed since our last inspection where concerns of this nature were also identified and shared with the provider.

The systems in place were not effective to ensure there was a culture of safety and learning from events such as falls and where people had become distressed or anxious and had hit out at staff. Processes had not identified, through provider audits, where there should have been shared learning for staff to improve safe practice and mitigate risk of reoccurrence.

Incidents and accidents had not always been reported, recorded, reviewed, investigated or appropriate action taken in response to these. This included a failure to investigate, for example why a fall may have happened, or to identify trends and patterns in these events. This meant any learning and improvements that could be introduced to mitigate future risk of reoccurrence had not been considered or shared with staff. In response to our assessment of this service, the provider has told us they have since introduced monthly accident/incident analysis audits.

Risk assessments and care plans failed to address known or foreseeable risks that put people at risk of avoidable harm. We found care plans were not always reviewed thoroughly after incidents had occurred, to ensure they remained effective. There was no record of ‘lessons learned’ from safety incidents that resulted in changes to improve the care and support for others.

People we spoke with did not raise any issues regarding safe transitions when they moved between services, such as hospital admissions.

The management team told us they had a better understanding of people’s care and support needs and when that support would need to be reviewed. They also told us people were referred for support from other health professionals when needed.

The management team explained to us they were in the process of introducing an electronic care management system to support the completion of care plans, risk assessments and daily notes. The registered manager told us, “We are setting up digital care plans, we have only been doing it 3 weeks.” They told us they believed this system would help them make sure care plans and risk assessments were kept up to date and accurate. The management team also acknowledged there remained work to be done with their care plans and risk assessments. This meant in the event of a person moving to another service, we could not be fully assured the information for that person would be completely accurate and reflective of the person’s needs.

Feedback from health care professionals showed how they felt progress was being made with the service by working together. However, people’s care records did not demonstrate that advice and guidance from external teams and professionals was consistently followed. Health professionals had recorded when they visited and left instructions for staff. However, some instructions were not always followed and systems had not identified when this had occurred. For example, pressure relieving equipment not being used when recommended by a health professional.

Feedback from the local authority told us the service shared their monthly action plan. However, the local authority, at the time of the assessment, had not visited the service themselves and completed their own compliance assessment of the service.

Effective systems were not in place to ensure safe systems, pathways and transitions were consistently in place and followed. The management team and staff told us care plans and risk assessments had been updated. However, we found reviews of people’s care plans did not always reflect their current needs and the support they required.

However, there was health information available in the event of a hospital admission and systems were now in place to support staff to identify when people required nursing care and they could no longer meet people’s needs safely.

People and their relatives told us they felt the service was a safe environment to live in. One person told us, “It’s nice here [the service]. I like living here, It’s nice to be with people. I feel safe here, it wouldn’t be nice to be out wandering around by myself."

Staff were able to explain the action they would take if they had abuse concerns. One staff member said, “I would report it straight away to the senior or manager.” However, 1 staff member was not aware they could also contact the local authority and CQC with any concerns about safeguarding people from suspected abuse should the registered manager or seniors be unavailable or implicated. Our discussions with staff and management highlighted a gap in their knowledge regarding their understanding of the Deprivation of Liberty Safeguards (DoLS) and when it was to be used in the best interest of people.

We saw that people were not always protected from avoidable harm resulting from unsafe moving and handing. For example, we observed a person was not supported to transfer using the correct moving and handling techniques, this included being supported under their arms. Supporting someone under the armpit is also known as a drag lift and can cause harm to people and staff.

We also observed staff attempting to help a person to the bathroom. Two staff tried to assist the person to stand up from their chair, but they were unable to. They did not have the strength in their arms to push themselves up. We heard 1 member of the staff say to the other, “We could scoop them up,” to which the second staff member replied, “No.” Both staff tried again, at the person’s pace, but they could not stand and the person told the staff to leave them where they were. No suitable moving and handling equipment was available to enable this person to access the bathroom which meant their care needs at that time were neglected as no alternative arrangements were offered to the person.

Effective systems were not in place to ensure people were protected from the risk of abuse and avoidable harm. There was a safeguarding policy in place. However, the registered manager, who was responsible for overseeing safeguarding, was unable to demonstrate how investigations into potential safeguarding incidents had been completed and if there was any learning shared with staff.

The guidance given in the provider’s safeguarding policy on when suspected abuse should be notified or referred to an investigating body did not reflect regulatory requirements or local authority safeguarding procedures. For example, the policy referred to the need to complete a mental capacity assessment and best interest decision being made before making such a referral.

Where required, we saw Deprivation of Liberty Safeguards (DoLS) authorisations had been applied for or were in place for people. However, the management team and staff would benefit from additional training to aid their understanding of what would constitute a deprivation of a person’s liberty.

None of the people or relatives we spoke with told us they were actively involved in the assessments of risks associated with them or their loved ones’ medical or care needs or development of plans to manage these. One relative told us, “[Person] does not like to get up and out of bed. However, on the odd occasion [person] does get up. They (staff) have a wheelchair for [person]. I don’t know how they get [person] into the wheelchair from the bed though. I don’t know if they have a hoist."

The management team told us risk assessments had been updated and were reflective of people’s needs. They told us they were reviewed monthly or when people’s needs changed. We found care plans and risk assessments were not always reflective of people’s current needs and had not always been reviewed and updated following incidents and accidents.

The management team agreed improvements were needed with the completion of risk assessments to ensure they were person centred and respected people’s choices about their care. Post the assessment process, the provider has told us they have started to take into consideration person centred care and respecting people’s wishes and choices and recording when people’s needs change.

Staff did not demonstrate a clear understanding of the known risks to people and their role in helping them manage these. Staff we spoke with gave conflicting feedback on how to support a person in the event of them falling or supported them to get out of bed. There were also conflicting responses from staff on how to monitor and prevent other health concerns including pressure damage to skin.

Staff gave examples of how they supported people who sometimes communicated their needs and emotions through distress. However, these did not always demonstrate how people’s emotions and distress were responded to in a way that encouraged learning for how their distress could be more positively managed in the future. For example 1 staff member said, “I leave [person] for a while for them to calm down and try again later."

One person at high risk of pressure damage to their skin was observed not wearing protective footwear that was provided by visiting health professionals with instructions for staff to encourage the person to wear them. There was no care plan or risk assessment in place to support staff with encouraging the person’s use of the footwear or how to approach the person if they refused to wear it.

At lunchtime, on the second day of our site assessment, in the dining room, it was observed that people were not offered hot drinks to accompany their mealtime experience and everyone was provided with a plastic cup to drink their juice from, which may undermine their dignity. There was no evidence of how people had been involved in assessing any risks associated with traditional cups or glasses.

One person was seen to have a kettle in their room and the registered manager told us the person did not use it. However, the person confirmed they did use it for ‘tea and biscuits’ when visited. There was no risk assessment completed with the person associated with their use of this applicance.

The processes in place to manage people’s risks were not always effective and people were placed at increased risk of harm. When incidents and accidents occurred within the service, risk reviews were not always taking place. When reviews had been completed, it was often documented no changes to people’s care were required, but these did not consider what factors may have contributed to the incident. For example, when people had displayed periods of emotional distress, we saw there was not always clear guidance within the care plans or risk assessments to show how staff should support people during these times.

Risk assessments that were in place were mostly followed by staff and were reviewed. However, most of the reviews we looked at were completed by a staff member who had not completed appropriate training. This meant we could not be assured that reviews were effective in identifying and mitigating people’s risks.

There was a limited and inconsistent approach to identifying and managing risks to people. People did not always have risk assessments or care plans in place for known needs or risks, so it was unclear what their current support needs were. For example, the management team told us 1 person chose to remain in bed and did not get up. However, this was not reflected in their care plan, risk assessments or conversations with some of the staff. Where there were risk assessments for this person, we found the information was conflicting on how or if they should be moved. This posed a risk to the person because the information and guidance was not clear for staff to follow to meet the person’s current individual needs. Post assessment the provider has told us they have started working through their care plans, reviewing their risk assessments and monitoring the changing needs of people.

People and relatives did not raise any concerns regarding the environment of the service.

We raised some concerns with the management team about fire safety at the service. They acknowledged the concerns and told us they were attempting to source a competent person to review their fire safety policies and procedures. The registered manager explained to us the maintenance person carried out a number of safety checks. However, when we asked for evidence to support the maintenance person had the necessary skill set to competently assess for risk, for example, in relation to fire safety, no evidence could be produced.

The registered manager told us they had completed full physical evacuation drills of the home. Staff spoken with explained what they would do in the event of a fire emergency. Staff told us they had fire training but this was on line theory based. One staff member said, “I have received fire training, it was one of the first things I did when I joined.” When asked if the fire training had included how to use a fire extinguisher (a practical demonstration of using a fire extinguisher), the staff member replied ‘No’ but it was something they felt they would benefit from. This meant staff may not be fully trained to use equipment for tackling small fires safely. This put themselves and people at the potential risk of harm in the event of a fire.

We discussed with the management team about the use of hoists when people’s needs change and they were unable to transfer without the support of staff or weight bear. The management team explained they would review the person’s needs and if they needed a hoist it would be considered; however, due to the layout of the home environment and space, it would be possible the person might need to move to an alternative location.

The management team told us they wanted to continue with the improvements to make the environment more dementia friendly. Some work had already taken place such as painting some bedroom doors a different colour.

There was a limited supply of equipment to consistently support staff to deliver safe and effective care. For example, there was no hoisting equipment or equipment to support staff to safely assist a person from sitting in their chair to a standing position to enable them to use the bathroom. This meant at that time, the person's needs were not being safely met.

There had been some work undertaken to introduce appropriate signage and orientation aids into the service; however, there was further improvement required. For example, the registered manager told us that there remained additional signage to be introduced throughout the building. It was observed that signage and orientation aids were not prevalent on the first and second floors.

Fire doors had been made safe and personal evacuation plans had been introduced for people and were available in the event of an emergency.

Effective systems were not in place to monitor the environment in relation to fire safety when fire wardens were not on site. The registered manager told us they and the nominated individual (NI) were fire wardens. Certificates showed the training for this role had been completed online, during our assessment, on 23 September 2024 (the NI) and 7 October (the registered manager). Evidence could not be provided for any previously completed fire warden training or renewals of this on an annual basis. Neither the registered manager or NI were regularly on site at the service during the night or at weekends. We were not provided with evidence to demonstrate any care staff were trained fire wardens. The provider’s own Fire Safety Policy stated, ‘It is the care service’s policy that an appointed fire warden should be on duty at all times.’

The basement was high risk, with no immediate means of escape other than to use the stairs to exit via the ground floor. The fire risk assessment and the fire safety policy did not account for the potential risk for staff being unable to exit safely, in the event of a fire starting in the basement. The provider’s fire risk assessment was written on a template designed for ‘landlords of small premises’ not an adapted, bespoke policy for a residential care home.

Equipment such as hoists were not available to support people whose mobility fluctuated. This meant there was a risk that people’s immediate care needs could be unmet when their mobility deteriorated or fluctuated.

The provider had fitted 4 doors with magnetic closures to comply with fire safety issues identified at the November 2023 inspection.

People and relatives raised no concerns about the number of staff available to support them with their daily needs.

Some staff spoken with shared with us they would benefit from more face to face training as on-line training was not the most effective way for them to learn. Some staff told us they were responsible for particular administrative duties and were also completing risk assessments and care reviews but had not received appropriate training in certain areas of care and did not previously work within health and social care environment. This meant staff had not always received the appropriate and relevant training to support them in their role.

No concerns were raised by the management team or staff during our conversations about the staffing levels. They told us they felt the service had enough staff to make sure people were safe.

On the day of our site visits, we saw there was no issue with staffing levels and there was enough staff available to support people. There was a staff member available in the lounge to support people when needed. Any alarm activations were responded to promptly and people were not left waiting for assistance. However, our observations showed that care staff were working in a task orientated way to accomplish their duties and did not always have the time to sit and talk with people. For example, staff providing people with their lunch in the dining room spent no time with them to explain what lunch was, to ascertain if the people had changed their minds about their meal option or ask if they wanted any more. To save on time, the staff gave people their yoghurt dessert at the same time as their dinner.

The training staff had received had not always been effective to aid their learning, such as dementia care and fire safety. For example, 1 staff member told us, “All the fire training was online, I don’t know how to use a fire extinguisher but that is something I’d be interested in learning.” We saw the provider’s fire policy referred to ‘small fires can be fought with the appropriate fire extinguisher… if safe to do so.’ Staff not receiving the appropriate training to show them how to use, or identify the correct type of fire extinguisher, could place them and people at risk of harm. Staff we spoke with told us they would not tackle a fire and would raise the alarm with the local fire service.

Most of the training was self-directed online learning with no evidence to demonstrate how the management team could be assured the training was effective. For example, we asked a staff member about their recent mental capacity training. The staff member was unable to recall what they had learned and could not demonstrate how they applied this learning in their role. Another staff member, who had completed a training session on dementia awareness, could not recall they had completed it. This evidenced training was not always effective.

The registered manager and nominated individual (NI) told us they would deliver face to face training, in addition to online training. However, there was no recorded training for either the registered manager or the NI on the training matrix to evidence what training they had completed. We could not be assured their knowledge and skill set met the required standard for competency to train others, such as completing a ‘Train the Trainer’ course.

Staff were safely recruited. This included checks relating to people’s suitability to work in the care sector. However, improvements could be made to ensure staff records contained all the evidence required to demonstrate safe recruitment as these records were not consistently readily accessible.

There were no concerns raised about the cleanliness of the service by people or relatives.

Staff and leaders raised no concerns in relation to infection prevention and control (IPC) at the service. Staff told us they were aware of IPC procedures, and they knew where personal protective equipment (PPE) was stored and when it should be used.

The registered manager and NI shared with us details of the advanced infection prevention control course they had recently completed to become infection control champions. They told us how much they enjoyed the course and said it was ‘brilliant’ and they had improved their knowledge. They told us they would deliver training and share their knowledge with staff.

The management team told us that since our last inspection they had been assessed by the local authority infection control team and any issues raised by them had been dealt with.

Communal bathrooms were clean and there was PPE available for staff and visitors to use when required. However, a sink located in the visitors and staff toilet required some additional cleaning. It is important care staff facilities are effectively cleaned and maintained to limited the risk of cross infection. We observed some care staff were wearing nail polish and jewellery. This meant there was a potential risk to effectively manage infection control because nail polish can trap bacteria and make it harder to clean hands. Painted fingernails may also lead to a risk of cross infection. We also noted on the first and second day of our assessment, the wall mounted hand sanitisers, located at the main entrance, and in the dining room were empty. This meant sanitiser was not readily accessible to people visiting the service to support safe IPC practice and had not been identified by staff or management they were empty.

Systems were in place to monitor IPC. However, these had not enabled staff and management to identify and respond to the issues identified above.

People and their relatives did not raise any concerns about the administration of medication. One person told us, “I have all my tablets. I’m in chronic pain all the time so I have the pain relief all of the time."

Staff told us they had completed their medication administration training and had their competencies assessed by the registered manager. However, when one staff member was asked how they disposed of a specific medication, they told us they wrapped the medication up in their original packaging and disposed of them in the general day to day waste. This was not compliant with national guidance.

The assessment team also found it had not been recognised that Apixaban was an anticoagulant. Discussions with the registered manager showed they had not recognised the risks for people prescribed Apixaban and there was no guidance for staff on what they would need to do in the event of an emergency. (Apixaban prevents blood from clotting normally, so it may take longer than usual for a person to stop bleeding should they be cut or injured)

Systems were in place to support the administration of medicines. This included training and staff competency checks. However, at the time of the assessment, the assurance processes had not effectively identified staff members were not disposing of some used medicines in line with national guidance. For example, safely disposing of used medicine patches applied to people’s skin. In response to this issue, the registered manager immediately introduced a policy to safely dispose of the used transdermal patches in line with NICE guidance.



The medication audit checks had not identified where people were on anticoagulant medication, or had allergies, there were no risk assessments in place to guide staff on what action to take in the event of the person receiving an injury that caused them to bleed or an allergic reaction.