Archived: Blackwater Mill Residential Home

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Requires improvement

• Caring

  Requires improvement

• Responsive

  Good

• Well-led

  Inadequate

Our view of the service

We carried out a responsive assessment of Blackwater Mill between 6 November 2024 and 7 January 2025. This assessment included six site visits to the home, two of these visits were conducted out of hours. Five inspectors and a medicines inspector were involved in one or more of the assessment visits completed.

Blackwater Mill is a care home that can accommodate up to 60 people. At the time of our assessment visits in November 2024, there were 38 people living at the service. While assessing the information received from the service additional concerns were shared with us from multiple sources. This resulted in us conducting two additional site visits to review the latest concerns raised and to establish if any improvements had been made following the previous inspections. At the time of our assessment visits in January 2025, there were 36 people living at the service.

During our assessment we observed care and reviewed people’s risk assessments, care plans and medicines administration records. We reviewed policies, procedures, training records, incident records and other relevant documentation.

The provider failed to sufficiently address the 9 breaches of regulation that were identified on our last inspection and continued to remain in breach of these. Additionally, we identified a further breach of regulation 20 (Duty of Candour).

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and / or appeals have been concluded.

This service remains in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

People's experience of this service

During the assessment we received mixed feedback from people and relatives about their experiences of the service and standards of care provided. Some people and relatives we spoke with expressed they were happy with the care and described the staff as being kind. However, others felt there was not enough staff available to meet their needs. this included a loved one’s personal cleanliness and a person not being supported to arrange a required health check.

During the assessment we found shortfalls in people’s experience of care which needed to improve. This included examples where we observed a person calling for help and was unable to seek staff support when they needed assistance due to the call bell equipment being out of reach. We also reviewed people’s personal hygiene records and were not assured people received regular baths and showers.

We made observations at this assessment and found elements of care did not always meet the expected standards. Shortfalls included people not always receiving food served was in-line with their assessed dietary needs and risk management requirements.

People’s experience of care was not always person centred and some people’s preferences in relation to dietary requirements had not been respected, for example if they disliked fish or pork this had been served to them. Some people’s preferences in relation to personal care had not been respected, for example, a person had expressed a preference for female only staff however, records demonstrated that personal care was being completed by male staff.

Where people at the service were living with a diagnosis of dementia, we observed the environment did not always reflect best practice guidance to support people with orientation.

People who were unable to join in the planned activities, were not supported to engage in meaningful activities and appeared to have limited interaction.