Bluebell Manor

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

This is the first inspection of this newly registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed. We found breaches of regulations in relation to staffing and medicines management. There were not enough staff to safely care for people or support their day-to-day needs. The provider had not taken in to account the geographical spread of the building. We raised this with the provider who increased daytime staffing levels after the inspection. Staff supervision records were not always detailed, staff did not always feel confident, when raising issues with management, that action would be taken. People felt that the service relied on too many agency staff which impacted on the quality of care. Agency staff were not always suitably inducted into the home. There was an effective process in place to ensure people had smooth transitions between other healthcare services. People were safe from the risk of abuse. Risks were managed and mitigated safely. There were occasions when staff member’s knowledge of risks was not as good as it could be. Medicines were not always managed safely, key documents were missing for a number of people. Records were not always consistent and one person had been adversely impacted by this.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt the service had a learning culture. One relative said, “I think the training is better than before, on top of the training the staff are reporting on care with handheld tablets. The cleanliness and maintenance has improved recently.” Some people were aware of residents meetings and some were not.

Staff were involved in meetings which included discussions of lessons learnt. Some staff told us were not always able to attend meetings due to the times of the meetings. They had raised this with managers but no changes had been made.

The processes in place did not always support a learning culture. Staff supervisions were not taking place regularly and there was limited opportunity for staff to express their view. There was no evidence that action had been taken following supervisions. Audits identified issues but these were not always recorded clearly or actioned in a timely manner.

People felt they received safe and effective support from different care services. The Bluebell unit was being used as a step-down service with staff from Bluebell Manor providing personal care and NHS staff assessing people’s future needs. Relatives commented that the doctor is always contacted quickly when needed.

Staff worked with, and felt supported by, health and social care professionals.

Healthcare partners felt safe systems were in place. One partner commented that the regular use of agency staff meant that continuity of care within the service was not as good as it could be.

Processes were in place to ensure smooth transitions and continuity of care for people. Robust pre-admissions assessments were carried out to ensure the service could meet people’s needs. Emergency healthcare plans were in place to ensure people received appropriate care in line with their wishes.

People felt safely cared for. When asked if they felt safe one person said, “I’m safe and comfortable here.”

The manager and staff recognised their responsibilities and duty of care to act on safeguarding concerns.

People appeared to be happy, comfortable, and safe in their surroundings.

There were effective systems, processes and practises to ensure people were safe from the risk of harm and abuse. Policies and procedures were available, and staff had attended safeguarding training and updates to refresh their knowledge and understanding. Safeguarding referrals had been made to the relevant external parties when required.

People told us they were involved in making decisions about their care and support. Relatives commented, "[Person has] not had any falls recently, they manage risk ok,” and “[Staff] manage risk yes and are proactive.” The provider had positive evidence of how staff managed risk, including a low incidence of falls on Millview and Wansbeck Units.

Staff supported people safely and used appropriate equipment safely. Staff did comment that they did not always have time to read people’s care plans thoroughly. When asked if they had time to read care plans to understand people’s needs, one staff member said, “No, sometimes you don’t know even about the resident’s mobility needs.” Other staff made similar comments. A person commented “The other day [staff] tried to lift me on the side I’ve had the operation. [Staff] are friendly but not always clued up on what people’s needs are.” This may not have happened if staff had more time to understand people’s needs.

Staff were available to support people when they needed help. During meals there were enough staff to support people eat safely, however staff told us that staffing in the dining room was sometimes lower than the days we were there.

Risks were assessed and mitigation put in place to minimise risks where possible. Most people had risk assessments for all key aspects of their care. We found occasions where some care plans were not in place for higher risk needs including diabetes and Parkinson’s disease. The manager took action to update these records immediately. A new electronic care planning system was being introduced during the inspection period. The management team felt this would help them manage risks to people in the future.

People said staff knew how to use specialist equipment. One relative said, “Mum is in bed, she is hoisted in and out. There’s no issues about safety.”

Staff told us they had received training in using equipment in the service. Staff had received training in fire safety.

People lived in a safe environment which was suitable for their needs. The service was clean and well presented. The provider was planning on refurbishing the service beginning in autumn 2024.

Maintenance checks were carried out regularly. Chemicals were locked away and doors to stairs and exits were locked with keypads to keep people safe. People had suitable personal evacuation plans in place.

People did not think the service was appropriately resourced with staff. One person said, “I get a shower when it’s available, I have one enough times a week. [Staff] are multi-tasking I ask when someone’s available, sometimes you have to wait, they have a variety of tasks to do. I hate the weekends Saturday and Sunday have no identity. The weekends are very quiet and very depressing, there are quite a lot of staff off at the weekends. I wish I could get out, I’ve never seen the garden. You need someone to push you and some days they are so busy.” One person told us they did not like to use their call bell regularly because they know how busy staff are. “I buzz four times a day for help going to the toilet. I do wait longer than fifteen minutes for them to come regularly to help me to the toilet.” Another person said, “The other day I wanted to go to the toilet – but I had an accident because I had to wait.” People also commented that the high use of agency staff affected the quality of care. One person said, “The regular staff couldn’t be better, agency staff could be better.”

Staff felt there were not always enough care staff on duty and the high use of agency staff negatively impacted their ability to care for people. One staff member commented, “Staffing levels are shocking as its unsafe for staff and residents and it’s really difficult to meet residents needs with 1 carer and 1 senior on a nighttime (on one unit), as the senior is doing [medicines] and the 1 staff member is busy with either personal care or doing supper trolley.” The management team had a dependency tool in place and felt this provided suggested, suitable staffing levels for the service. Overall staffing levels were also skewed by one unit having a contractually required number of staff, independent of the occupancy level. However, we found this meant staffing levels were too low across the remainder of the service, meaning people were at risk of harm due to the layout of the building and the spread of people. Following the inspection the provider took action to increase staffing.

Staff appeared rushed. We carried out a visit in the early hours of the morning after people told us they were being woken and got up early for the convenience of staff. One person told us she had been got up early that morning, a staff member said this was because the person was a falls risk and it was easier to make sure she was safe when sat in the foyer not in her room. This meant that people were being imposed on at staff member’s convenience rather than their own preferences.

Processes were in place to calculate staffing needs however, the calculated number of staff of impacted negatively on people’s quality of care. Gaps in staffing were filled using agency staff, but the high usage of agency staff also impacted on quality of care, agency staff did not always have a detailed induction to the home and people’s needs. Staff had raised concerns about staffing in supervisions and a staff survey however no action had been taken. We raised concerns about staffing with the provider, following the inspection the management team increased the staffing levels on day shifts and formalised a procedure to support the Wansbeck unit. Staff were recruited in line with best practice guidance. Appropriate documentation regarding sponsorship for overseas staff was in place.

People felt safe from the risk of infection. One person said, “Yes, the place is clean, they are here every day, especially [housekeeper].”

Staff took appropriate action to reduce the risk of infection. PPE was used when required. Staff were trained in infection control practises.

People were isolated and supported appropriately if they had an infectious disease in line with current best practice guidance. The laundry was exceptionally clean.

Processes were in place to keep people safe from infection. Infection control and monitoring audits were carried out by the management team and any identified issues acted on.

Records demonstrated that people were receiving their oral medicines as prescribed. However, one person’s medicated patch had been applied at the incorrect frequency. Guidance to support staff in the safe administration of when required medicines were in place but required further development to ensure they contained person specific information. We also found the service did not always follow their own policy when administering ‘when required’ medicine, for example administrations and their effect were not always recorded on the reverse of the Medicine Administration Record. On the day of inspection, the provider was undertaking a transition from paper care plans to electronic. We found that for some people no care plan was in place on either system. For example, for one person with a complex condition of diabetes no care plan was in place. For another person we found instructions from a recent hospital admission in relation to elimination needs had not been actioned, placing this service user at risk of further hospital admission. No care plan had been implemented in relation to this need, placing them at further risk. During the inspection the provider took action to rectify the issues we found.

Staff told us they had completed a lot of work to ensure medicines were given safely and the appropriate competency assessments were in place. We raised with management regarding the archiving of medicines administration records as we found historical documents from 2023 in a treatment room. We were told this is an area for improvement. This was further corroborated when the service could not provide historic patch records for one person. Audits were taking place in the service however, had not always identified the issues we found.

Medicines were stored securely and safely including controlled drugs however, temperature monitoring on unit demonstrated large gaps in recording for July 2024. Processes to manage topical medicines required improvement to ensure they were robust, for example guidance documents were not always in place or contained enough information on where to apply them. We also found inconsistencies in where staff were recording the application of topical medicines.