Archived: Bloomsbury House

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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

Our rating for this key question remains inadequate with a continued breach of regulation for poor governance systems. There were governance systems in place; however, these were not effective in identifying the concerns we identified/observed during this assessment.

Staff understood their role and responsibilities. Managers supported the performance of staff. Notifications had been submitted to external organisations as required. Leaders worked in partnership with local authorities and quality teams.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with shared a passion for the service and care for the people living there. Staff and management understood the importance of listening to the views of people and their relatives about the service. The registered manager explained how they gained feedback from as many visiting professionals and relatives as possible.

The nominated individual (NI) and registered manager shared with us how they would use this feedback from our latest assessment for learning and improving the service. The NI told us, “It’s good to have a fresh pair of eyes (looking at the service).” However, in our conversations with the management team, they did not demonstrate a clear understanding of current regulatory requirements and best practice guidance, or a robust strategy to address challenges at, and drive improvement in, the service.

There was evidence that feedback was sought from people, relatives and visiting professionals. All the feedback about the service, the staff and the care was positive. However, there was no evidence to support how the provider had used that feedback to make further improvements to the service. There was a lack of a clear, structured planning process to ensure meaningful collaboration with people who use the service, staff and external agencies to support any strategic goals and how these might be achieved to deliver safe and good quality care for people. We did not find evidence of an effective processes to monitor and review progress against the delivery of a strategy to ensure care reflected current best practice and regulatory requirements. This was evidenced in the lack of overall improvement in the service over the course of the last inspection and this assessment.

Staff training was not always delivered in an inclusive manner. For example, some staff told us training was delivered via e-learning which was not every staff member’s preferred way of learning. Some staff told us they would benefit from more face to face training and interacting with their colleagues.

The registered manager and NI told us about the additional training they had received in relation to infection control and how they planned to share their learning through face to face training with their staff. However, there was no evidence to show us the registered manager or the NI had the necessary skills to deliver training to their staff, such as ‘train the trainer’.

Staff told us the management team were accessible and approachable and they felt supported. If they needed to speak to the management team, they were easy to contact. One staff member said, “[Manager name] is always available to speak to if needed."

The registered manager and NI told us they had been in the care sector for circa 30 years. During our conversations with the management team, it was clear they lacked the knowledge and necessary skills to understand how and why their service had failed to meet the fundamental standards of care set out within the regulations. For example, the governance systems had failed to identify the concerns we had identified such as poor care plans, poor risk assessments and staff not following a consistent approach to support people to manage and mitigate risk of potential harm. All of which form an essential foundation to providing a safe, effective, caring environment for people living at the service.

While there had been some improvement within the service relating to the monitoring of people’s weights and nutrition, we found other improvements identified at our last inspection, in November 2023, had not been implemented and remained an area of concern. For example, mental capacity assessments, poor risk assessments and inconsistent care plans.

The registered manager and NI were receptive to our feedback and where possible made immediate changes in response to that feedback. For example, introducing policies for head injuries and disposal of certain types of medication. Post assessment the provider has shared with us the improvements they have continued to make in relation to involving people and relatives in care reviews, seeking feedback from people about their personal preferences and continuing with the implementation of their electronic care system which they say will help them improve their care plans and risk assessments.

Managers were in the home Monday to Friday and at weekends, a senior carer was present at the home. A 24/7 on call system was in place so managers could be accessed as required.

Staff told us they knew how to raise concerns. However, not all the staff were aware they could report any concerns directly to the Care Quality Commission and the local authority’s safeguarding team. One staff member said, “I’d Google who I could contact outside (the home)."

We were not assured that there was an effective whistle blowing policy in place. We requested to see this policy on 2 occasions because a previous copy had been sent to us in an inaccessible format and it could not be reviewed. Therefore we could not be sure the policy provided the correct information for staff. Conversations with some staff demonstrated they were not always sure who they could report any concerns to.

Staff felt the management team treated them fairly. For example, where staff needed to work in a flexible way, this was discussed with the registered manager and alterations to staff’s working patterns would be made. Staff felt the home provided them with a good work life balance. Staff told us they attended supervisions.

The provider had policies and procedures in place that promoted workforce equality and diversity. However they had not ensured staff training was accessible to all staff, taking into account different learning styles. Some staff told us they would prefer face to face training to promote learning and share experiences.

The registered manager told us they had audits in place. These audits included topics such as infection control, medication, fluid and bowel monitoring, and daily walkarounds. However, we found concerns with the effectiveness of the audits as they had not identified the concerns we found during this assessment.

The registered manager showed us they had a training document to monitor when staff had completed their training. They told us they would regularly check and review staff training was being completed.

The service’s governance systems were not effective in enabling the registered manager and provider to have effective oversight of safety and quality at the service. Assessments of people’s care needs were being completed by staff that had not been appropriately trained. Accident and incident forms were not analysed to identify trends and check appropriate action had been taken to mitigate any future risks.

The training matrix contained some anomalies when compared to a previous matrix which meant we could not be fully assured when staff had completed their required training in, for example, pressure care.

The provider had failed to identify that some of their policies had not referenced the correct legislation or did not reflect current good or safe practice. For example, the provider’s fire evacuation policy was not based on the correct legislation.

People and relatives told us staff assisted them in arranging support from other healthcare services as needed.

Staff and managers told us how they collaborated with all relevant professionals, stakeholders and agencies, such as district nurses and general practitioners.

Stakeholders told us they had good working relationships with the service and did not share any concerns with us.

The processes relating to collaboration with external stakeholders had improved from the last inspection. We could see from care plans health care professionals were contacted when people’s needs had changed or there were concerns regarding people’s health. However, professional advice was not always followed when this was given. For example, when community staff left guidance for pressure relieving equipment to be used, this had not been followed by staff.

The provider told us about the improvements they had made following our last inspection. However, they agreed more improvements were required. Staff also told us about the improvements made to the home. The registered manager spoke about their plans to improve the decoration of the home and how the introduction of their new electronic care planning system would benefit monitoring of the service and embedding good practices. Unfortunately, during this assessment, the electronic plans themselves were not present to review as they were only just being uploaded onto the system.

We shared our concerns during the assessment with the management team around missing information and the lack of detail in care plans and risk assessments. The registered manager admitted there was still a lot of work to be done with the service.

Systems and processes to support learning and improvement in people’s care were not always effective. Not all incidents and accidents were robustly investigated to determine if there were any trends or check if appropriate mitigation plans were in place. While we saw there had been some improvement with the monitoring of people’s dietary requirements and their weight, there had been a lack of action to identify and act on other areas where improvements were required. We found some repeated issues at this assessment as we did at our previous inspection.



Staff had been supported to develop their skills and knowledge. However, their training had not always proven to be effective with some staff not being able to recall how the training had benefitted them in their day to day role.