Bluebells Care Home

On this page

• 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 how people were kept safe. We found improvements had been made to the culture of learning within the service. Lessons had been learnt when incidents happened, and action had been taken to reduce the risk of them happening again. The service was clean, and improvements had been made to the decoration. The equipment people used was maintained to make sure people were safe. Staff understood how to protect people from discrimination and abuse. There were enough trained staff to meet people’s needs. Medicines were managed safely.

This service scored 75 (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 lessons had been learnt and action taken to keep their loved ones safe after an accident or incident. One relative told us, “My relative has had falls. These have reduced by a considerable amount since [registered manager] and [deputy manager] have been managing the home. I am always contacted when my relative falls”. Another relative told us action had been taken promptly when another person had entered their loved ones bed room on a couple off occasions. The action had been effective and this no longer happened.

The management team described the process the provider had in operation to learn from accidents or incidents. This included completing regular audits, looking at patterns and trends. This was completed for people as a whole and individuals to identity anyone who may be at increased risk. Action had been taken when any patterns had been identified, for example, if a person fell more than once at a particular time, checks were put in place before the time to support the person and avoid the risk of them falling. Staff confirmed changes were made when things went wrong and issues did not reoccur. One staff member described the process as, “We try to nip things in the bud so they don’t happen again”. For example, when a person tried to leave the building without staff support and this put them at risk of harm, action had been taken to keep them as safe as possible. This had not impacted on other people who continued to be able to go out when they wished. The registered manager told us complaints were rare and any complaints received were reviewed to ensure any necessary improvements were implemented.

There were effective processes in place to identify patterns and trends. Accidents and incidents were recorded and analysed, action was taken to reduce the risk of them happening again. Actions were reviewed to make sure they had been effective, if not changes were made. There was a complaints policy, this was followed and any lessons learnt were discussed with staff to reduce the risk of them happening again.

Relatives told us they were confident to speak with a member of the management team if they felt there was a risk of something going wrong. One relative told us, “I would contact the manager or assistant manager, but have not had reason to do this. They are both very helpful in every way and I could approach them about anything”. Another relative commented, “Initially I would go to the management of the home, [registered manager] or [deputy manager]. If I wasn’t getting the correct response I would contact the provider”. One relative told us they had discussed their relatives wishes regarding going to hospital with the management team and plans were in place to support them. Other people reported their relatives had not needed to be transferred to other services, such as the hospital so they were unable to comment on this.

The registered manager described to us the process they completed to assure themselves they had sufficient information about people to meet their needs before they moved into the service. This included meeting with people and discussing their needs and goals and inviting people to visit the service to look around and choose a bedroom. This information was used to understand any risks to people and write an initial care plan which was shared with staff before the person moved in. Staff confirmed they knew about people and their preferences before they moved into the service.

Healthcare professionals did not have concerns about people moving into the service or the information given to other services when people moved.

The registered manager had an admissions process in place which included several staff and was recorded to ensure people received all the information they needed including how to make a complaint, support to personalise their bedroom and sharing dietary needs including likes and dislikes with kitchen staff. A similar process was in place to support people to move to other services for short or long term stays. These included important information about the person, including how to support them if they became anxious or upset, how to communicate with them and medicines.

We observed staff supporting people to remain safe. People were supported to use their mobility aids when moving around the service. Staff reminded people to wear the correct footwear and to sit in the appropriate chair to remain safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and relatives told us they had no concerns around the safety of the building of equipment.

Staff told us they felt the environment was safe. They told us the garden was accessible to everyone and people and their relatives had enjoyed barbeques there. Staff confirmed they had all the equipment they needed to care for people safely. One staff member told us the maintenance person was very responsive and would come to the service to address issues even when they were not on duty.

We observed the building and equipment had been well maintained. Work was underway to redecorate a corridor and some bedrooms. Other areas had been redecorated and were light and airy. Consideration had been given to best practice guidance for environments for people living with dementia. For example, floor and wall coverings were plain and all areas of the service were well lit. Easy to understand signs were used around the building to support people to move around freely and we observed people walking to the areas they wanted to be. One person who had recently moved into the service was seen practicing using the lift to aid their independence. The garden was accessible with step free access. Paving was well maintained and did not pose trip hazards to people. There was enough space for people to move around freely. The rear garden was secure.

The provider had effective systems in operation to maintain the the building and equipment safely and quickly remedy any shortfalls. Regular checks were completed on equipment such as fire safety equipment, beds and mattresses and lifting equipment. The fire alarm system had been updated and fire drills had been completed so staff were confident to move people to safety if needed.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and relatives were confident in the infection control measures in place at the service. They commented the service was “clean” and “fresh”. One relative told us, “I turn up as and when, and never found the place unpleasant. It’s spotless”.

Staff confirmed they had completed training in relation to infection prevention and control (IPC) and their skills had been checked. They told us personal protective equipment (PPE) was always available to them and stocks were maintained. Staff explained it was everyone’s responsibility to restock PPE, soap or towels when they were running low. Staff confirmed they were able to wear face masks if they or people felt reassured by this. The registered manager told us they completed infection control checks and audits to make sure they systems they had in operation were effective. These included observations and competency checks of staff washing their hands and using PPE. They told us staff completed infection prevention and control training annually with an external trainer, the next course was booked for shortly after our site visit.

All areas of the service we observed were clean and odour free, this included bathrooms, toilets and people’s bedrooms. Limescale had been prevented from building up around sinks and taps and showerheads were descaled regularly. All areas of the home were free from clutter where dust or dirty could build up. The laundry room was exceptionally clean and tidy. Systems were in operation to prevent clean laundry being contaminated by soiled laundry. There was no build up of dirty laundry and clean items were returned to people promptly. We observed soap and paper towels were available at each hand wash sink. Stocks of PPE, including disposable gloves and aprons were available around the service and were easily accessible to staff. These were worn by staff as necessary. The provider had a commissioned a specialist company to dispose of any soiled waste. Bins had been used correctly and emptied frequently. Infection control had been considered when purchasing furniture and floor coverings and were easy to clean. All the furniture and flooring we saw was clean and odour free. People who use equipment to move around had their own slings which were washed regularly.

There were effective systems in place to monitor the cleanliness of the service and staff practice. The management team completed regular audits to check the service was clean. Staff competency was checked regularly to make sure they were following best practice guidelines.

We observed people receiving their medicines. Staff told people what their medicines were and made sure they wanted to take them before they were administered. They explained throughout what they were doing, for example, sitting people upright to reduce the risk of them choking on the medicines and offering them a drink. They waited until people were ready to take their medicines and chatted and laughed with them once they had been administered. One person told us staff provided their medicines in the way they preferred. They told us there was a risk they may drop their tablets so staff gave them to them on a spoon and this reassured them none would be dropped and missed. They confirmed they received their medicines every day as prescribed.