Archived: Blackwater Mill Residential Home

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• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

We assessed 3 quality statements within this key question. We found 1 breach of the legal regulations in relation to person-centred care. This breach was a continued breach of regulation.

People's preferences in relation to their personal and intimate care needs were not being met. We observed some people looking unkempt. People did not always receive timely support from staff and this compromised their dignity.

People’s care plans did not always contain sufficient guidance for staff to manage specific conditions and enable them to provide consistent support to people.

People's care plans did not always contain information about their personal, cultural, social and religious beliefs and those we reviewed contained limited and basic information about people’s interests and what was important to them.

People who were unable to join in the planned activities, were not supported to engage in meaningful activities and appeared to have limited interaction. We observed long periods of isolation for some people without meaningful activity or engagement, especially for those who spent time in their rooms or were cared for in bed.

People did not have choice and control over their care, treatment and wellbeing. We observed a person who was in wet clothing and unable to call for assistance as their call bell was out of reach. Some people’s bedrooms were dirty and cluttered. Some bedrooms smelt strongly of urine.

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.

Relatives told us staff were kind to their relatives. Comments included, “They always demonstrate kindness towards [relative].”, “From what I’ve seen the staff show empathy towards residents.” and “Some very caring staff. New recruits seem lovely.” However, relatives did raise issues around their relative’s cleanliness and not having a bath or shower as often as they would like. A relative told us, “My other concern is personal cleanliness. In the time [relative] has been in there they have only had 3 baths/showers as they are incontinent, they always have a smell about them, I have brought this up from time to time but they [staff] always say they cannot force [relative] to wash.”

Although most relatives did not raise any concerns about responses to their relative, one relative told us, “We have noticed many times; residents calling out for help or just simply being left alone.”

Staff we received feedback from told us they maintained people’s dignity during personal care. One staff said, “We can ask their permission. We can explain what we are doing. Close the door and curtains for their dignity.” Staff also told us they spend time with people to have a chat when they can. A staff member told us, “Resident whose family come in gets upset when they leave. Usually put the kettle on and have a chat. Make time to have a chat, sit with them for 5 minutes.”

A visiting professional raised concerns relating to a person’s care and well-being needs not being met. For example, a person was found with their call bell out of reach and a water jug however there was no cup. Their clothes and bed sheets were dirty. The person had bruising to the shin however, at the time of the professionals visit there had been no recorded entry in relation to the unexplained bruising.

Further concerns raised about the staff’s knowledge of people, the professional was informed that the person did not have a low bed or a sensor mat in place, however, both pieces of equipment were observed as in use. This raised concerns around the care homes view of this person’s capacity and whether assessments had taken place around the use of equipment that could be viewed as restraint.

A recent move of bedroom for this person to a different part of the home on the same floor had restricted the regular interaction they had with another person living in the service.

Another professional described Blackwater Mill as a 'constant merry-go-round' during their involvement with the service.

A further professional felt that ‘some of the staff are not competent at all and some care records are being completed by staff who do not know the residents’. For example, “[Management] wrote a load of PRN protocols and they were awful. They don't know the residents. Some were for medication people weren't taking any more. One of PRN protocols on the system is for someone who cannot verbalise pain but staff are directed to ask if they are in pain. Pain relief (Paracetamol) is never given. This is one of hundreds of examples”.

We observed an inappropriate sign that read ‘Welcome to the Nut House’, this was identified on our previous inspection in March 2024.

We observed a person who was in wet clothing and unable to call for assistance as their call bell was out of reach.

Some people’s bedrooms were dirty and cluttered. Some bedrooms smelt of urine, we were told by a staff member that a person’s bedroom smelt as ‘they were diabetic’, and a member of the management team told us another person’s bedroom smelt due to the ‘family dog visiting’. We observed a person with a urinal bottle on their bedside table next to their breakfast.

We observed a collection of slippers and laundry bins labelled ‘women’s blouses’, which did not give assurance that people's personal clothing was maintained, this corroborates feedback from relatives that people are often dressed in other people's clothes, or clothes that do not fit them.

We noted a lack of attention to detail, for example we observed a person’s personal belongings stored in several clear plastic boxes in the corner of their bedroom. We observed incontinence aids on a hallway floor and personal toiletries belonging to a person in communal drawers in a hallway.

Most relatives we asked for feedback told us staff knew their relative well. Although not every relative confirmed this. One told us, “They do not know either my [relative] or our family at all.”

There was praise for the activities team, although an issue was raised about one relative not getting up in time to attend the sessions. This meant they missed out on things they would like. A relative said, “Activities staff have been fantastic. Phoned day before so they were ready for activity. At 10.50 they were still getting [relative] dressed and activity, Tai Chi, had already started. Another occasion at 12pm they were getting ready to shower [relative], they didn’t get a shower but had an all over wash. Didn’t do the activities. Activities on in the morning start at 11am and [relative] was not up.”

Staff told us care plans were a work in progress, they were getting better but needed improvement. Although staff said they knew people, the care plans didn’t always reflect the knowledge of people supported. Staff had not always had time to go through the care plans to find out about people. One staff told us, “Haven’t had an awful lot of time to go through them as a lot to do on the floor and get to know the residents.” There was no mention of people’s protected characteristics or histories from staff we spoke with. However, one staff did support one person’s religious beliefs saying, “For example, one resident who was here, maintained their church dress on Sundays. We prepare for those days to have a shower and get the dress ready.”

We observed long periods of isolation for some people without meaningful activity or engagement, especially for those who spent time in their rooms or were cared for in bed.

People were often in their bedrooms with no entertainment, for example radios and televisions were not on. We noted one person had a lake view but was unable to see it as their chair was positioned too far back and they were unable to move it independently. This was raised on our last inspection in March 2024. An inspector moved the chair for this person who was very happy.

We observed a group activity in the lounge on 7 November 2024. The activity was colouring and crafts and there were 8 people present. There was a nice atmosphere and for the people involved they appeared engaged and happy.

Care plans did not always contain sufficient guidance for staff to manage specific conditions and enable them to provide consistent support to people. For example, a person living with dementia had no detailed information in their care plan to support staff to understand how their dementia impacted them as a person and how they were to be assisted. Care plans for people had conflicting information, some were generic, lacked detail and were not always person centred. Records lacked detailed guidance on how best to support people’s communication needs

Care records were often contradictory. For example, a person’s care plan described ‘being around others as making them feel better’, however it then refers to ‘being left alone’. A person described as benefiting more from one-to-one activities however, there were no details on how to facilitate this, how sensory activities may benefit them and the best ways staff can include and stimulate them.

People's care plans did not always contain information about their personal, cultural, social and religious beliefs. Those we reviewed contained limited and basic information. Audits of care plans had not generated sufficient improvement. These had not identified the conflicting and contradictory information as well as the lack of person centred detail.

Records of activity provision demonstrated mixed experiences. For those able to join in planned activities there was variety on offer. However, for those cared for in their rooms, there was minimal evidence of meaningful activity being offered. Activities recorded were task based, for example shave, brushing or washing hair.

Over a 61 day period there was less than 15 hours social activity recorded for 3 people. For 1 person there was 13 days over the 61 day period where no social activity was completed.

Relatives told us they were able to be more involved with the new manager in place. The manager listened to their concerns and gave feedback. Although relatives said this was an improvement over the previous management, there were still issues which prevented people being as independent as they could be.

We received information that people were told they could urinate in there incontinence pads as, “That is what they are for” and “whilst not suggesting that the home contributed to [relatives] death, the care was poor”.

Relatives told us that, “[Relative] would often be dressed in other residents clothes.” Another relative told us, “I visit 4-5 times a week and often find [relative] doesn’t always look like they have had personal care”. They told us they have raised this numerous times but whenever they do the same thing happens “nothing”.

People were not supported to maximise their mobility which would have enabled them to be more independent. One relative said, “[Relative] was in a wheelchair for a bit, and [staff] weren’t assisting them to walk as easier to wheel around in wheelchair. Then had a bed sore as left in bed. Now resolved as [relative] is walking a lot now. [Relative] is very strong and can walk.” Whilst another told us, “My [relative] has always insisted they wanted to come home to their family, friends & community, after their initial "Six Week Reablement" which has not happened.”

Staff we received feedback from told us they knew it was important to maintain people’s independence where possible. Comments included, “[Resident] needs a bit of assistance for personal care. So, we get the stuff on the flannel and still give it to them to use. I would put the shower on and squeeze the shampoo in their hands so they can wash their hair themself. We don’t want to take away their independence. May need a bit of help but let them do what they can.” Another told us, “Encourage them as much as possible. We would support them and not take their independence away from them. When the time comes, we will give them some more support.” However, during our inspections staff we spoke with told us that “We don't normally do bath's just bed washes,” and “We are always busy and there is never enough time, very few baths are carried out and many are bed bath's.”

Staff also told us they supported people with outings in the community but these weren’t often.

During one of our out of hours visit we observed a person whose personal care needs took 1 hour and 14 minutes to complete due to insufficient staff. The person required support from 2 staff however, they were left during this time period for 23 minutes with 1 staff as the 2nd member of staff needed to tend to the continuous buzzers going off. Two other people were found asleep in the dining room at 23.29pm. Whilst one was assisted to bed at 12.22am, the other person remained in the hallway on our departure at 02.30am. The person made several attempts to get upstairs using the keycode, however, these attempts were unsuccessful. There was no staff intervention or encouragement to guide and support them to bed.

At approximately 12.40am a person was heard calling out from their bedroom. The inspector knocked their door and entered. The person was lying in bed with the main light on, the person wanted their light turned off. There were no visible staff around carrying out proactive checks on people.

Records showed a sudden change in recording of washes as "bath (bed bath)”, which gives a falsely “improved” picture of the number of showers and baths being provided. An in depth review of records showed that baths and showers were not an option for some people and washes or full body washes were the recorded choices on the system.

During the month of October, one person described by staff as enjoying a bath had no baths and only 1 shower, another person had received 1 bath, and a further person had 1 shower. We were concerned people continued to experience a lack of choice and control over their personal care needs.

A personal hygiene care plan for a person describes 'All care interventions need to happen by Female Staff Only’, however, daily records indicated that male staff were tending to their personal care needs.

We were not assured people received food in line with their preferences. We noted people recorded as disliking fish or pork had been given these meals. This was also raised on our last inspection in March 2024.

Records indicated long gaps between the evening meal and breakfast. Some records indicated that a snack had been offered in the evenings, however, several records indicated people were either 'asleep' or 'refused'. We reviewed records for people who required assistance from staff with their nutritional needs and identified gaps as long as 16.5 hours between food and for one person on 1 occasion a 20 hour gap.

We did not look at Responding to people’s immediate needs during this assessment. The score for this quality statement is based on the previous rating for Caring.

We did not look at Workforce wellbeing and enablement during this assessment. The score for this quality statement is based on the previous rating for Caring.