Archived: Blackwater Mill Residential Home

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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

We assessed 4 quality statements within this key question. We found 2 breaches of the legal regulations in relation to good governance and notification of other incidents. These breaches were continued breaches of regulation. Blackwater Mill has been rated required improvement or inadequate within the well-led domain for the last 4 consecutive inspections completed by the Care Quality Commission (CQC). The breach relating to good governance was a continued breach of regulation and had been identified at the last 3 inspections.

The provider’s governance systems were inadequate and failed to recognise a range of shortfalls in people’s care and the service. There were not effective systems in place to assess monitor and improve the quality and safety of the service. The was a lack of robust oversight from the provider and checks of the quality of the service were not being consistently completed. Actions had not been taken to address previous shortfalls that had been identified by stakeholders, professionals and CQC.

There remained a lack of evidence of a positive learning and improvement culture. The provider has current conditions on their registration to send us an updated monthly service improvement plan. Some of the actions on the plan were recorded as met, however we continued to find concerns.

The provider failed to ensure they informed the Care Quality Commission of notifiable events at the service where they were legally required to do so.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

None of the staff we contacted were aware of a vision or strategy for the home. Staff told us morale had improved, and they were happier working there than before. Comments included, “As of now it is getting better, and we try and support each other and the residents also.” and “I am very much happy to be here working in this care home.” More senior staff acknowledged there had been issues saying, “Obviously, there are things that could be done better, that’s what I’m here for. Sometimes carers are afraid to ask for help from myself and seniors.” Also, “Staff morale has changed a lot as was so down when I first came in.”

Whilst we noted actions aimed at making improvements, there remained a lack of evidence in support of a positive learning and improvement culture. There had been changes in management and in the format of oversight. This made it difficult to track specific actions through to completion. Improvements had not been made and embedded quickly enough to support people or staff and to drive a positive culture.

There appeared to be an ongoing lack of engagement with people who use the service to seek and use their feedback to improve the service. Plans to involve people in reviewing their care were recorded as ‘not started’.

We noted examples of action taken to engage with staff and relatives of people who use the service. For example, a staff meeting in August 2024 recorded supportive messaging to staff around incoming management and sentiment such as ‘together we can achieve’. A relatives’ meeting from October discussed the rating of the service and indicated relatives had been given the opportunity to voice their feelings and concerns. The primary concern noted was poor communication. At the time of our visit, it was too early to assess the impact of this engagement.

There had been staff turnover, including of managers leading to inconsistency in leadership.

Staff were positive about the new manager, being supportive, approachable and having an open-door policy. One staff said, “Manager is a very lovely lady and team leader. I hope she can carry it forward and bring the home back to its flourishing stage. Very supportive to staff and a dedicated leader.” Whilst another told us, “Manager is great. Since she has started there have been so many positive changes. If she stays it will get to where it should be.” However, feedback received regarding the senior management team was not always positive and there appeared to be a culture of blame when things went wrong.

Although there was positive feedback about the new manager, they submitted there resignation in January 2025.

There continued to be a significant turnover in the service management. Since our last assessment in Spring 2024, two new managers had been in post. The manager in post at the time of our visits had joined in the service in September 2024 however, during our visit in January 2025 they had submitted their resignation. A new deputy manager who joined in the service in September 2024 had also resigned in January 2025. There had also been changes in the heads of care roles. Soon after our visit, the representative of the provider, closely involved in the management and oversight of the service, resigned. In our previous assessment, we noted concerns over the safe recruitment of staff, in relation to the completion of Schedule 3 checks. We were still not assured all appropriate checks were being carried out.

Since our last visit, the provider reported progress in establishing a system of staff supervision, with most staff recorded as having participated in a meeting. At our last inspection we had been told that the home was developing 1:1 supervision sessions with staff to enable a more positive culture of learning and to develop and to be able to tailor staff training plans to their specific learning needs. However, we found very little evidence of 1-1 supervision sessions taking place and the supervisions that had occurred were group ones.

Following our visit, the manager sent us an updated version of the service improvement plan. The format of the document had been updated and was now divided into areas of focus, for example care plans, medication or infection control. The document was work in progress and not all actions had been assigned or given timescales.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Although most staff told us the home was well managed, there were areas still needing attention. This included staffing and care plans. Staff said, “(Well-managed) Yes, in my opinion. Only for the staff shortage but otherwise very well managed.” Whilst another told us, “(Care plans) Lot to do when started. Most are up to date, and we are still working on them. Catching up from April/May time.”

Staff did not go in to detail on how they thought the home was well managed, but staffing and care planning still needed to be addressed.

The provider’s systems to monitor and improve the quality and safety of the service were still not effective. We continued to identify concerns in relation to the management and mitigation of risk. Areas of concern, identified and flagged to the provider at our last assessment and in our last report, persisted and this impacted on people’s safety.

We noted ongoing concerns in relation to people’s choice and specific needs relating to food and fluid and continued reports and observations of call bells being placed out of reach. Whilst the provider’s audits and improvement plans acknowledged these and other risks, there was a lack of timely or sustained improvement, and this put people at risk of harm.

Other actions, noted to have improved by the service had not been sustained, for example repositioning records were noted to have improved at the start of October 2024 yet by the end of the month it was recorded, ‘Repositioning still going for long periods without intervention.’

People’s care records contained gaps and inconsistencies. Records were not being maintained to be accurate, up to date and consistent.

Some areas, such as the environment received positive reports from the internal support visits, a directors visit in August 2024 describes an action as, “Head of Infection Control coming out from council. Need to get deep clean sorted before then”. However, we did not observe the home to be ‘clean, tidy and odour free’ when we visited.

During this assessment, we identified 10 breaches of regulation, of which 9 breaches are continued breaches. The provider’s systems had not enabled them to make and sustain improvement or to identify they were not meeting the requirements of these fundamental standards.

The provider had failed to notify CQC of incidents in line with their legal responsibilities. We identified incidents including death of service users and sexual safety concerns that had not been shared with us.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Although staff knew about falls protocols and what happened afterwards such as monitoring by senior staff, the feedback we received was mixed as to whether continuous learning was taking place. One staff said, “They (management) will ask us whole scenario as to what has gone wrong and how to rectify it, even the staff off shift coming back to make sure it doesn’t happen anymore.” However, it was unclear if some responses were happening in isolation rather than being cascaded down to staff. Another staff told us, “If someone has had a fall, we assess the area for example if fell over a mat. [Resident] had been playing with mat and cable, so talked to [management] about getting a mat for their chair so they don’t fall over the wire.”

The provider had made insufficient progress to improve the safety and experience of people living at the service. Breaches relating to people’s safety and the governance of the service, identified at our last and earlier inspections, were not met. The measures in place to assess, monitor and mitigate risk to people’s health, safety and welfare had not delivered timely results and people remained at risk of harm.

There was not yet a clear and coordinated approach to deliver improvement in the service. Agreed actions were not always monitored to completion or sustained. For example, in mid-September 2024 it was agreed a senior member of staff must oversee the dining room at mealtimes, yet in October 2024 an audit of the mealtime experience noted ‘no seniors present to help until asked.’ Other items appeared each month on the improvement plan with little evidence of progress. For example, gaps in the administration of topical creams appeared in audits over a 6-month period. In the October 2024 audit, we read, “Someone needs to take ownership of the creams.” This showed a lack of improvement over a 6-month period of an identified failing.

There was no evidence of learning through incidents and the home did not have a process in place to analysis trends and themes in relation to falls. This meant referrals to appropriate external bodies would have been delayed due to trends and themes not being identified. This was confirmed by the manager.

Internal audits showed progress in some areas, for example systems for bowel monitoring and checks on mattresses and bedrails were recorded as being in place. However we were not assured these were effective as we identified an airflow mattress set at almost double a person's body weight.