Blossoms Care Home Limited

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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

The rating for the key question of Well led has deteriorated from Good to Requires Improvement. Systems and processes were not effective in assessing, monitoring and improving the quality of the service. The provider was in the process of making changes. However, these had not been embedded into practice at this inspection. Throughout our inspection at Blossoms Care Home Limited, we identified several shortfalls in the safety of the service. This resulted in us finding concerns related to the oversight of the service. This led to a breach of the Regulation 17 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider failed to ensure effective oversight to assess monitor and improve the quality and safety of the service. Systems and processes had failed to identify and mitigate risks when insufficient levels of trained staff were deployed. This put people at risk of not having their needs met. Reviews and audits of people’s care files and risk assessments had not always been completed and therefore, had not identified when information was missing or inconsistent. Systems and processes to audit or review daily task records or mitigating strategies were not effective. Systems and processes had failed to identify health and safety concerns.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Not all staff understood the vision and strategy of the home. Staff did not always feel supported by management which effected the culture of the service.

The provider was aware of best practice guidance including equality and human rights. However, processes to share the vision of service was not always effective.

The provider was open and transparent throughout the inspection. Staff told us they felt supported within their roles

The provider provided training and learning sessions especially for managers.

Staff knew how to whistle-blow and knew how to raise concerns with the local authority and the Care Quality Commission (CQC) if they felt they were not being listened to or their concerns were not acted upon.

Staff and people’s relatives told us they had been asked to feedback on the service The provider was aware of their duty of candour responsibility and had systems in place to ensure compliance

The provider completed right to work documentation as required. Staff completed equality opportunities forms on application to their role. The provider made reasonable adjustments if required. Staff told us they were offered regular meetings and supervisions to share information.

People were protected against discrimination. There was a policy which covered the Equality Act 2010 and protected characteristics.

The provider had failed to ensure effective oversight to assess monitor and improve the quality and safety of the service. Systems and processes had failed to identify and mitigate risks when insufficient levels of trained staff were deployed. This put people at risk of not having their needs met. Reviews and audits of people’s care files and risk assessments had not always been completed and therefore, had not identified when information was missing or inconsistent. Systems and processes to audit or review daily task records or mitigating strategies were not effective. Systems and processes had failed to identify health and safety concerns.

The provider was open and transparent regarding the issues we found. After this inspection the provider sent updated action plans, and new documentation which was being started to improve practices and support safe care and treatment for people. However, we are unable to evaluate these as they have not been embedded into practice.

The provider told us they worked in partnership with key organisations to support care provision, service development and joined-up care. However, a staff member told us, "We do not have enough staff to do the administration work, book, attend and follow up on GP appointments or answer the phone."

Processes were not always effective in ensuring all staff worked in partnership with others. When something went wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again.

Relatives told us the staff did not always keep them up to date on any changes, incidents or accidents relating to their loved one

The provider was open and transparent with the commissioners of the service.

Systems and processes were not in place to identify trends and patterns from incident and /or accidents to ensure lessons could be learnt

Staff did not feel information was always shared to make improvements and learn from mistakes.