Archived: Blackwater Mill Residential Home

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• 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

We assessed 7 quality statements within this key question. We found 5 breaches of regulations in relation to safeguarding, safe care and treatment, staffing, fit and proper persons employed and duty of candour. The breach relating to duty of candour was a new breach. The remaining breaches were continued breaches of regulation. Blackwater Mill has been rated required improvement or inadequate within the safe domain for the last 9 consecutive inspections completed by the Care Quality Commission (CQC). The breach of safe care and treatment was a continued breach of regulation and had been identified at the last 3 inspections.

The provider did not operate systems and processes to learn from safety events or incidents at the service to improve the quality of care for people. The provider failed to act in an open and transparent way when incidents and accidents had occurred.

The providers safeguarding systems and processes were ineffective, and we were not assured that people were appropriately protected from the risk of avoidable harm. Risks to people's health, safety and wellbeing had not always been identified and guidance for staff on how to mitigate risks was not always available, was inaccurate or was contradictory.

The provider did not ensure people were supported by staff who had the relevant skills, knowledge and training to meet their needs. The providers recruitment practices were not in line with requirements to ensure they followed safe recruitment processes when new staff were employed.

We observed shortfalls in the infection control practices of the home and processes were not robust to protect people from the risk of infection.

People’s medicines were not safely managed and people did not always receive their medicines as prescribed.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from relatives was mixed. Some were generally positive about staff listening to them and improvements since the last inspection, whilst others still had some serious concerns. These included personal cleanliness, lack of showers, and how an attack on their relative was handled. Relatives said the manager was good at getting back to them and most medical issues were resolved, however, there were still things raised which had not been addressed such as a sink not working properly, weight updates and eye tests.

Staff told us they were able to raise concerns, and they were listened to. Staff we spoke with said there had been issues with previous staff, but this had now changed. Although staff knew who to report to, they were not always clear on how incidents were investigated and lessons learned were embedded.

A senior management member of staff told us that they had been told accidents to people were not reported to RIDDOR and this only happened if it was a staff member who was injured.

The provider failed to demonstrate they had embedded effective processes to identify, monitor and promote learning from events at the service. There were no formal processes in place to ensure identified learning from events was consistently shared with staff.

There was no robust systems in place to review and analyse incidents to ensure that appropriate action was taken to mitigate any known risks to people. For example, we found multiple incidents where sexual abuse had potentially occurred, however, there was no evidence available which demonstrated actions had been taken to fully investigate these incidents, mitigate future risk or detail how the service planned to ensure people’s ongoing safety.

On review of records we found multiple falls had occurred at the home. Processes in place were not effective or robust to ensure appropriate consideration was given to review mitigating factors or identify possible patterns, themes, trends and causes.

We identified the service failed to effectively act on previous concerns shared with them. For example, we found lack of action had been taken to mitigate the risk of choking and that people continued to receive food that was inappropriate to their needs. There continued to be a lack of guidance for staff around specific medical conditions, including Asthma and seizures.

Since our last inspection there were no records to demonstrate that the provider acted in an open and transparent way when incidents and accidents had occurred or that accidents and incidents had been reported appropriately. For example, concerns or injuries had not been shared with partner agencies, such as RIDDOR, the local safeguarding team and CQC as required or with relevant persons in line with Duty of candour requirements.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Although most relatives we spoke with said their relative felt safe, there were a number who raised concerns. One relative told us their relative was safe and they were confident things were improving. Another said, “No, not at all, as my [relative] has told us on more than one occasion that they feel frightened.” Concerns had been raised over general and oral hygiene, medicines and falls. One relative had raised an issue of medical concerns not being followed up unless they complained. There was also an incident where 3 people who were supported by the home were attempting to leave the building via the front door preventing relatives from entering. Staff did not appear to be able to cope with the situation. It was clear communication could have been better when a person went into hospital and improvements still needed to be embedded.

Staff we spoke with knew when they last had safeguarding training and what things to report. This included physical abuse such as bruising, psychological abuse and harm including medicines errors. However, staff did tell us people who wanted to go for a walk outside of the home were not able to due to lack of staff to support them.

Observations throughout the assessment showed organisational abuse and neglect. On our out of hours visits we observed people were being woken up at midnight to have their medicines delivered which were prescribed to be administered at 8pm.

A person, assessed as needing support from staff to eat using a teaspoon due to choking risks, was found alone in bed with a cold bowl of porridge eating with their hands, there was no cutlery present. The person had food around their mouth and on their clothing. We observed a staff member trying to put a spoonful of food into another person’s mouth when they were not fully awake, which then caused unnecessary distress and agitation to the person. This placed them at risk of choking. We raised safeguarding concerns to the local safeguarding team following our site visits.

Where people had an authorised Deprivation of Liberty Safeguards (DoLS) in place, conditions had not been met. For example, staff were to support a person daily to the dining room for lunch, however during our on-site visits throughout 3 days, this person remained in bed and there was no record of the person being supported out of bed. This condition had been valid for 8 months.

Another person had a condition to move to a different room where they could see out of the window and see the television, although the person was in a different room from our previous inspection, they were still unable to see out of the window. This condition had been valid for 10 months.

The provider failed to ensure effective and robust processes and systems were in place to protect people from neglect, abuse and improper treatment.

People were placed at risk and not protected from sexual abuse. The service failed to take effective and timely action to keep people safe, the service failed to put in place appropriate mitigation to prevent sexual abuse and assaults from happening. The service failed to notify safeguarding and CQC about the true extent of the incidents that had occurred. People were placed at continued risk of harm due to the services failure to act.

We identified concerns of the services safeguarding systems, processes and practices. The processes were not robust as records did not demonstrate robust investigations had been completed where incidents, accidents and near misses had occurred to prevent and mitigate future risk. On review of the services training matrix, we found not all staff had up to date safeguarding training and found there was a lack of understanding by both staff and management of what constituted abuse. This meant people were at risk of continued harm and neglect.

Mental Capacity Act (MCA) assessments and best interest decisions were not always completed where required which meant we could not be assured staff protected people's human rights in line with the MCA. We were not assured the provider consistently met their legal requirements where people were deprived of their liberty. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found examples where the provider failed to ensure that conditions attached to some peoples DoLS were complied with.

Relative’s we spoke with had mixed views of the improvements at the service. Risks around hygiene still needed to improve. This included hand washing and showering. However, risks with food had been identified and staff (especially kitchen staff) were addressing these with generally positive feedback about the food, with one person eating what he liked now. The only exceptions were not managing food and fluid consistency properly, and some of the food being too spicy for elderly people. The main concern from relatives was having to tell the staff what risks or issues needed to be followed up. Not all of these had been addressed, such as getting an eye test to manage a certain condition.

Staff we spoke with knew about NEWS scores, who took them and what they did about them. However, a senior member of staff told us they were, “Aware of NEWS but not 100% on RESTORE.” Staff were also aware of risk with food and drink consistencies and where to find the information. Staff told us where details about people could be found, however, one staff member said they could have more information about a person’s history.

We heard a person calling out, they told us that they had been forgotten. They were lying in bed and wanted the light turned off and a drink as they said they were thirsty, their call bell was out of reach. The following day we heard the same person calling out in pain in their abdominal region, the inspectors escalated this to staff. Staff needed prompting by the inspectors to seek medical assistance for this person.

People were at increased risk of dehydration as drinks on over the bed tables were found out of reach for some people.

A person was observed in bed with their pressure mattress set at 35kg more than their body weight. This would reduce the effectiveness at minimising the risk of pressure damage and may have increased the risk. Bed rail covers were not always on bedrails and some with covers that still posed a risk of entrapment due to the full length of bedrails not being covered.

Risk assessments described toiletries to be in locked away due to the risk of ingestion, however we found examples of this not happening, with toiletries found in communal furniture drawers and accessible to people.

We found significant shortfalls in the providers risk management processes. We were not assured people consistently received safe care and treatment. For example, risk management plans were not always in place, robust or contemporaneous to reflect the care people required. These included risks associated with the management of people's dietary needs to manage the risk of choking and dysphagia where they had a prescribed modified diet.

The service was using Restore2 and News scoring, a tool used to detect early signs of deterioration in people. Staff were recording scores which indicated people were unwell yet this was not being appropriately escalated to relevant medical professionals. This increased the risk of significant harm to people through lack of appropriate, timely medical intervention.

We found significant shortfalls in people’s repositioning records and the provider could not demonstrate that people had been supported with repositioning in the time frame they had been assessed as needing to maintain their skin integrity.

Care records for people who had specific conditions such as Asthma, Parkinson's disease and Diabetes were not sufficiently detailed or robust to ensure staff had all the information they required to safely meet their needs. For example, where a person had a diagnosis of Parkinson’s disease and were prescribed medicines for symptom control, there was no specific care plan or risk assessment in place to support and guide staff around the importance of time sensitive medicines.

We reviewed weight records as some people were losing weight, this was especially evident for those cared for in bed or needing assistance with their nutritional and hydration needs. There were no processes in place which demonstrated that the provider took action to monitor and manage the weight loss that people had experienced.

Although one relative told us things had improved, with safety measures such as stair gates in place, there were still issues with the home. This included a sink being blocked in a room and not being used, and the room looking, smelling and feeling tired. Having a blocked sink not draining is a risk of legionella. There were also concerns raised about the uneven flooring being a falls risk.

Staff told us they had received fire safety training. Staff we spoke with said they knew what to do in the event of a fire and had regular fire drills. However, we were not assured of the effectiveness of these, comments included, “Maybe a month or 2 ago. It was ok, wasn’t the best, some staff faffed a bit”. Another staff member told us, “Fire drill, not a full scale one. They have explained to me how we would evacuate residents, but not where we have had to leave the building”. Some staff told us having more fire drills would be better.

Staff also told us they checked equipment such as hoists before use and they were inspected regularly. They said if not safe to use they would contact maintenance to get it resolved. Although staff were positive about the environment, one staff said, “The dining room needs something. It is used for a dining room/lounge. It is too small for the numbers of people we have got.”

We observed multiple of call bells which were missing in a number of bathrooms, and no emergency alarm pulls, even though bathrooms were freely accessed by people. This meant people could fall in these bathrooms and be unable to call for help. We observed call bells were placed out of reach of some people and movement alert equipment installed to keep them and others safe was not being used as intended.

We observed electric heaters in a communal area which were hot to touch and not covered. Some cupboards which should be locked were found unlocked, this included a sluice room and a cupboard with exposed pipework . The door to boiler room was unlocked with access to hot pipes. This put people at increased risk of burns.

We observed a sink in a person’s bedroom which was not draining properly and therefore could not be used. We observed a bath which had standing water in the drain, which could increase risks of legionella. Legionella is a bacterium that can cause a severe type of pneumonia (legionnaires disease).

We observed overloading of multiway extension leads with an extension lead plugged into another extension lead in a person’s bedroom under their bed, this could cause the plug in the wall socket to overheat and possibly cause a fire.

The corridors had very creaky floors, some doors banged loudly and the call bells sounded constantly, including times when they reverted to "emergency" alarms, which were significantly louder. This created a loud and disruptive environment for people at night time.

We were not assured that fire drills had taken place in accordance with the provider's policy. Whilst the fire risk assessment had been signed off as fire drills complete, conversations with staff as detailed in feedback from staff and leaders did not give us assurances. This potentially could cause staff to behave inappropriately if fire breaks out which placed people at risk of an unsafe evacuation.

We identified fire door compromises which were identified on our last inspection in March 2024 and on the providers fire door survey in April and November 2024. A door that led from the dining area to an activities office was cluttered with overloaded electrical cables from equipment, such as radios and chargers, this was not a fire door. Two bedroom doors had their locks removed forming a hole through the door. Fire doors are designed to resist the spread of fire for a period of time, normally a minimum of 30 minutes. The absence of fire doors and removal of these locks breached the integrity of the fire doors which placed people at risk of harm in the event of a fire.

The provider’s Legionella risk assessment, dated October 2023, noted action from previous Legionella risk assessments did not appear to have been actioned. On our November 2024 assessment there was a lack of documentation supplied by the provider, we were therefore not assured that all actions had been completed.

The service record for bath which we observed as having standing water in the drain was dated May 2024 and showed that the bath was not working or in use. There was no evidence to demonstrate that the provider had carried out the required repairs to ensure people on that floor of the service had access to a working bath.

Relatives we spoke with were mixed over the home having enough staff. Some told us there were enough staff, saying, “On my visits there are always plenty of trained staff on hand to tend to my [relative’s] needs.” and “There always seems to be enough staff around looking after residents.” However, others said this was a problem saying, “No, we believe that they are dangerously understaffed. We have noticed many times; residents calling out for help or just simply being left alone.” and “With regard to the point of enough staff, this is where I feel the home really falls down.”

Relatives did raise the issue of high turnover of staff and continuity of care. One relative told us, “Turnover of staff a bit of a problem.” another said, “What concerns me is that there is a huge turnover of staff at all levels in the home, and in my opinion, there are not nearly enough care staff working there.”

Relatives were also mixed on whether staff had enough training. Some thought they were well trained and observed good moving and handling practice. Others said they needed more training, especially in Alzheimer’s care, pressure sores, fluid and dietary intake, communication and hand washing.

All the staff we spoke with told us more staff were needed. One staff said, “Only thing I wanted to mention to you is the staff shortage, especially for the personal care. Sometimes I struggle to finish bathing, shaving and repositioning etc due to less manpower.” Whilst others told us, “I think we do need more staff if I’m honest” and “There just not seem to be sufficient staff to take people to the toilet.”

Staff also said there was a high turnover of staff with new staff not staying very long. Staff told us, “Many staff members who come to work here do not stay long-term.”

Staff had raised staffing issues as a concern with the provider back in August 2024. This was raised at a directors meeting in August 2024, comments included, ‘still get complaints from staff about lack of staff, but they are not working efficiently’.

One staff said, “I think maybe some of the staff could have more training in dementia.”

We completed multiple on-site visits to the service during this assessment and observed insufficient and ineffective deployment of care staff throughout the day and night which impacted how care was delivered.

Staff were rushed and unable to provide adequate support, particularly proactive checks of people, including re-positioning and supporting personal care. Some people were still in bed up to 11am and some people were up beyond midnight. We expressed concerns that people were not being given sufficient fluid and food due to the lack of staff presence.

On both of our out of hours visits, the medicines round did not finished until after 00:00 having started at 20:00 and some people did not receive their prescribed medicines due to insufficient trained staff.

We observed a staff member delivering care to a person single handed. The person required the assistance of 2 staff. Staff were having to cut short personal care to get to the next call.

We expressed concerns that, despite an additional management staff member attending during our first out of hours visit, they did not step in to support the staff or respond when we highlighted that people may require support.

We made observations of people who were cared for in bed or spent time in their room and found staff had very little time to provide meaningful engagement and interaction with them.

We were not assured there were sufficient numbers of staff deployed to appropriately meet people’s needs. The providers staff dependency tool was not effective and did not demonstrate people’s changing and increasing needs had been correctly assessed, reviewed or considered to help ensure staffing levels were sufficient to meet people’s needs. Due to safety concerns the local authority have been providing management oversight and additional staffing since 15 November 2024.

We were not assured staff received all training relevant to their role and training records identified shortfalls. Examples included ensuring staff were suitably trained and skilled to support people with specific conditions such as Epilepsy, Catheter care and Parkinson’s Disease or Promoting independence / independent living and End of Life Care. The training matrix showed shortfalls in training being completed and or refreshed for the new senior management team.

Where staff were carrying out care tasks to support people, we were not assured that all staff had appropriate competency checks in areas relevant to their role. For example, a moving and handling competency identified a staff member as not checking equipment for faults prior to use and not communicating effectively with the person.

Recruitment checks were not always carried out in line with the law. The provider’s policy referred correctly in relation to the requirement of obtaining satisfactory evidence of conduct and satisfactory verification of why employment ended, however the provider was not following these processes. Although we discussed this and provided the relevant information to the management team after our previous inspection in March 2024, the records we reviewed on this inspection for new employees identified the provider was still not ensuring that all the necessary pre-employment checks were completed.

Relatives we spoke with had mixed views on the cleanliness of the home. One relative told us, “The sink is blocked and doesn’t drain. Hygiene is a concern.” Another relative said when asked if the home was clean, hygienic and well maintained, “Yes, but I think it will always be a problem for them. Food remnants on the floor in the early days but [staff] would send a cleaner if I mentioned it. Now it seems alright in [relative’s] room and corridors, but I can’t comment on the lounges and kitchen.”

A relative we spoke with also raised concerns staff weren’t washing their hands. They told us, “Where are the paper towels going as no bin in bathroom? Are staff washing their hands?”. This matched with what we saw during our site visit.

Staff we spoke with told us they had received training in infection prevention and control (IPC) online and face to face although most were not sure when.

Staff also said they had enough personal protective equipment (PPE) and knew when to use it. However, not all of the staff we spoke with told us the importance of good hand hygiene, whilst others had to be prompted.

Staff we spoke with did not raise any concerns about the cleanliness issues we found in the home.

The environment was observed visibly unclean in some areas. Poor cleanliness was observed throughout the home of floors, toilets, bathrooms, and corridors. Some carpets were found to have stains and some carpets un-vacuumed.

There were several areas of the home that had extremely strong smells of urine. One person’s room was extremely malodorous of ammonia and urine. Staff told us it was because they were "diabetic and did not always pull up their pad". Staff told us that another bedroom which was malodourous, was due to "the visiting relative’s dog".

During our out of hours visit we observed poor hygiene practice. Staff moved between rooms with soiled items without the appropriate PPE being worn. This could lead to staff uniforms becoming contaminated and cross-infection between people supported. There was also no evidence of good hand hygiene during this time.

A bathroom on the ground floor containing a clinical waste bin with contaminated waste, did not have a yellow bag in place meaning the waste was not contained properly and staff would have to manually transfer the waste to a bag to dispose of it.

People were at risk of infection from the practices we observed during our inspection.

We could not be assured that systems to prevent and control infection were robust or effective. There were concerns with infection control within the home. Although cleaning schedules were in place, they were not always completed and proved to be ineffective based on the poor cleanliness of the home.

The provider did not provide evidence of an annual infection control statement or a named infection control lead in compliance with best practice guidance.

We found significant issues with the cleanliness of the environment and staff practice which demonstrated audits had been ineffective in driving improvement. Not all staff had been trained or were up to date in infection prevention and control.

Most of the relatives we obtained feedback from told us they had no concerns with medicines and their relative was receiving them when they should. One relative told us, “Yes, I am assured as I check occasionally. There is sometimes a chart in [relatives] room and whatever is prescribed is being given at a regular time and nothing is being missed.” However, there were some relatives who had issues over their relative’s medicines administration. This included having to chase the home for medicines such as hydrocortisone cream, iron tablets and pain relief. One relative told us, “[Relative] was prescribed hydrocortisone cream, but I had to chase this up for a few days until they eventually received it" and "[Relative] is currently anaemic and still hasn't received correct iron tablet.”

The lack of when required and variable dose protocols were discussed with a member of the senior management team. We were not assured that the service had a clear plan for the content and location of these protocols either in an electronic or paper format. Therefore we were not assured of the proper and safe use of medicines by the service.

When we raised concerns about out of date medicines reference sources, staff agreed to remove the folder and described how they would obtain additional information. This was raised in our last inspection in March 2024.

Staff were able to describe how they identified creams to be applied as part of personal care, apply them and record their application. However the applied cream was not always recorded in the record in more detail other than "cream applied" and where. Whilst staff were aware of the risks associated with one type of medicine to residents, they were not aware of the risks other medicines posed to staff of chid bearing potential.

The provider had failed to address concerns that were identified at the previous inspection in March 2024. For example, in respect of the secure storage of some medicines and ensuring that medicines reference sources were in date.

Fridge temperature records at the previous inspection in March 2024 indicated the maximum fridge temperature was outside of the maximum recommended temperature. Records since that inspection indicates that no actions had been taken since to investigate the record. Records of a second medicines fridge were also outside of their recommended temperature range and no action to investigate or resolve the concerns were recorded.

We reviewed the medicines administration records for 13 residents. These indicated for a few people medicines were not administered as they were not available. A few people were not being administered their medicines because "patient refused" or "patient asleep" on multiple occasions during the 28 days we reviewed without escalation or review.

When required and variable dose protocols continued to not be available to support staff administer these medicines consistently. This was of particular concern where people lacked capacity to request these medicines, for example pain relief.

Further concerns identified at this inspection included discrepancies between the contents of the Controlled Drug safes and their relevant registers. These were investigated and resolved by staff when we raised our concerns.

We reviewed the personal evacuation plan summary for the service. The fire risk associated with creams used as part of personal care had not been described within the document.

Whilst one person had a positive behaviour support plan, the plan did not refer to the person's when required medicines to support their behaviour. Therefore we were not assured of the proper and safe use of medicines by the service.