Archived: Blackwater Mill Residential Home

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• 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

We assessed 3 quality statements within this key question. We found 2 breaches of the legal regulations in relation to consent and meeting nutritional and hydration needs. These breaches were continued breaches of regulation.

Nationally recognised assessment tools used to ensure people’s needs were identified and managed were not being used effectively to minimise risk to people.

People’s needs had not been fully assessed and staff lacked clear and consistent guidance on how to support them and meet their needs. There was a lack of routine monitoring of people’s care and treatment to ensure positive and consistent outcomes. This placed people at risk of harm.

The provider failed to demonstrate how they considered best practice guidance where people were living with dementia.

Some people received food of an inappropriate texture to meet their needs and keep them safe, others had received food that was not in line with their personal preferences.

We found consent to care and treatment was not always sought in line with the law and guidance.

The provider failed to ensure they consistently met their legal requirements where people lacked capacity to make decisions, and leaders of the service failed to demonstrate they had sufficient knowledge and understanding of their legal requirements.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We were told a person was not supported by the provider to see an optician due to an eye condition. The relative told us, “[Relative] has suffered a few falls which might be a consequence of their failing eyesight, and I asked the home to arrange for an optician to examine [relatives] eyes. Over a month later nothing has been done and I am going to have to sort this out myself as I feel it is too important an issue to leave any longer. I am not happy about that.”

Not all of the relatives we contacted said they were involved in their relative’s care planning. Of those that were, it was mainly due to them wanting to be involved and making sure the home took notice of their views. Some relatives told us they had not been asked to be involved in their relative’s care. One relative said, “We have not been invited in regard to my [relative’s] care.” With another saying, “Until 2 weeks ago I have not had input unless I really complained.” However, there were some relatives who attended care plan reviews and were actively involved in their relatives’ care plans since their admission. The involvement with and communication from the home was inconsistent.

Staff did not tell us about how and when people’s needs were assessed. They were also unaware of people’s communication needs and where these could be found. Although most staff said there was enough information in the care plans, some staff we spoke with had not read the care plans of people they supported. One staff member told us, “I’ve read one but haven’t had time to read them to be fair.” Whilst another said, “They are a work in progress. Getting better but needs improvement. I think a lot of it is the wording as some overseas staff have been doing them or didn’t have proper knowledge. 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. I have had a quick look.” This meant staff were unaware of people's needs, including their accessibility and communication. This put people at risk of poor care.

Systems and processes were not being used effectively to ensure people’s needs were reviewed regularly or when things changed. Although we identified reviews of people’s care plans were completed, these were ineffective and failed to identify they lacked detail, and information was incorrect and contradictory. The lack of clear guidance put people at risk of receiving inappropriate or inconsistent care. For example, a person had specific instructions from the district nursing team in relation to repositioning however, staff were not following this. Information recorded about the equipment people used differed from what we observed was in place.

There was a lack of clear and person-specific guidance for staff relating to hydration. For example, people who had been assessed as requiring a daily fluid target had no hydration assessments in place. There was no information that gave guidance on the risks of dehydration or information on what to do if the targets weren’t met, for example, who to contact and what actions to take.

Relatives we contacted were mixed over the home providing support about their relatives’ health. Although the home had acted promptly in some cases, this was usually after relatives had raised concerns. One relative told us, “I have been informed when [relative] has been unwell, and has required medical support.” Whilst another said, “[Relative] has a poor swallow, I had to request SALT assessment.” Two relatives had concerns over pressure sores, with one relative telling us, “[Relative] had a pressure sore, and I had to demand that a district nurse visited ASAP to apply the specific dressing quickly as staff said they were going to put a plaster on it.”

Most of the relatives who gave us feedback said the food in the home was good and had improved in quality and choice recently, although there could be more vegetarian options. However, some relatives raised concerns about their relatives not getting the appropriate food, drink and support to meet their needs. One relative told us, “[Relative] was not being given the correct "Special Dietary Requirements" i.e.... "Level 1 Fluids" & "Level 5 Foods" and “They would often put sugar in [relatives] drinks, give sandwiches and then would have trouble digesting & walk away to leave [relative] to it.” Another relative told us that their [relative] is at risk from choking yet has found their [relative] being given food when not sat in the right position. This put people at risk of harm.

Staff who we got feedback from knew to check what foods and drinks people could have, as well as the consistency of these. They told us the care plans had the information and there were sheets in the dining room, kitchen and people’s rooms if they were on modified diets. Staff said they were confident they knew how to prepare these, what each person required and if they had any allergies.

Assessment tools were not used effectively to minimise risk to people. For example, RESTORE2 is a tool used to detect early signs of deterioration in people. This was not being used correctly and when people became unwell their condition was not monitored or being appropriately escalated to relevant medical professionals. Staff had not received training in using the RESTORE2 tool or had their competencies assessed in taking clinical observations.

Malnutrition Universal Screening Index [MUST] risk assessments referred to some people as requiring to be weighed weekly however, these were being completed monthly. We identified people who were losing weight. One person had a weight loss of 18.36% however, no referral had been made by the service to a dietitian. The referral was made by the hospital after the person’s unplanned hospital admission.

There was no effective systems in place to demonstrate any analysis being completed for people who had reduced fluid intake. We reviewed hydration records for 7 people who had a target of 1500mls of fluid per day. Two people who could freely access the dining area had exceeded their targets regularly however, for 5 people who spent time in their rooms, dependent on staff assistance or cared for in bed, fluid intake was not sufficient and, on some days, only 500mls was given.

The provider did not demonstrate they had considered all relevant best practice guidance for dementia friendly care environments. For example, we found the home lacked appropriate consideration of orientation for people, especially within hallways on the first floor. There were no tools in place to support people to make choices around their meals such as visual plates or photos.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

Relatives told us their relative was given choice where they were able to choose. They also said they were involved in decisions such as vaccinations and having their photo on social media when their relative was unable to consent. Although relatives feedback on consent to care was generally positive, one relative said they had not been involved in their relative’s care, “We have not been invited in regard to my [relative’s] care.”

Staff knowledge around people’s consent and the Mental Capacity Act 2005 (MCA) was mixed. Some staff knew what the MCA was for and what it meant for the people they supported. One staff told us, “Can’t presume they lack capacity, supported to make decisions. Act in their best interests.” Whilst other staff did not understand the MCA as well, telling us, “You have to sign something. If they can’t consent, then the next of kin or advocate.” Some staff did not tell us they had received training in MCA or what it meant to them in practice. This meant not all staff were able to ensure people’s rights were met with consent to care and treatment.

The provider failed to ensure the correct procedure was followed in relation to the Mental Capacity Act 2005 (MCA). Mental capacity assessments for people with a diagnosed impairment to the mind or brain were not always completed for specific decisions, such as welfare checks, photographs and modification to peoples diets. Where people had equipment in place to alert staff to their movements, this had not been assessed as a restrictive measure and to be in their best interest.

Where people had been assessed as lacking mental capacity to make informed decisions in relation to photographs and videos being shared on the providers public Facebook page, the provider was unable to demonstrate why this was in the person’s best interest.

Mental Capacity Assessments and Best Interest Decisions were not fully completed. For example, some best interest decision records did not include dates of conversations or elaboration of the action being taken and why it was deemed to be in the person’s best interest. There was evidence that some decisions were being made for people without consultation of other people who knew them.

There was no evidence people were provided information to make informed decisions and consent to their care. The quality of the capacity assessments were variable, some reflected differing information about whether someone did or did not have capacity, and whether their capacity was assessed in relation to their care planning, or individual decisions in the moment.

We found examples of best interest checklists completed by senior team members indicating an advance decision to refuse treatment (ADRT) was in place, yet there was no evidence to support this.