CQC report explained · a residential care home
What the CQC found at Blackbrook House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Risk assessments were not always effective or followed, and some healthcare advice was missing from them. Medicines were mostly managed safely, but some instructions and handling practices needed improvement.
- Effective?
- Good
- People's needs were assessed and care plans supported their needs, choices and preferences. Staff were trained, people received support with food and drink, and staff worked with health professionals.
- Caring?
- Good
- People and relatives described staff as kind and caring. Staff knew people well, respected privacy and dignity, and encouraged people to make choices and remain independent.
- Responsive?
- Good
- Care plans contained detailed information about people's needs, preferences and routines. Activities were varied, communication needs were considered, and complaints were recorded, although some complaint responses were missing.
- Well-led?
- Good
- The manager was visible and approachable, and the culture was described as open and positive. Audits took place, but they had not always identified concerns such as gaps in food and fluid monitoring.
What inspectors found, January 2020
Rated Good overall; inspectors found kind, effective care, but safety needed improvement.
This was an unannounced inspection on 25 November and 6 December 2019. Inspectors spoke with people living in the home, relatives, staff and health professionals. They also checked care plans, medicines records, recruitment, training and quality monitoring.
The home was rated Good overall. Effective, caring, responsive and well-led care were all rated Good. People and relatives spoke positively about the care, staff knew people well, and inspectors found enough staff at the time of the inspection.
Safe was rated Requires Improvement. Risk information was not always followed or updated, and some medicines arrangements needed correction. Some food and fluid records, complaint records and end of life plans also needed improvement. The management team acted promptly on issues found during the inspection.
Kind and respectful care
People and relatives were positive about the care. Staff knew people well and supported them with compassion, dignity and respect.
“The culture of the service was positive, kind and caring and the staff team were motivated and passionate.” from the report
Good care planning
Care plans included people's needs, preferences and routines, giving staff useful information about how to support them.
“People's care plans were detailed and had information about people's specific needs, their personal preferences, routines and how staff should support them to ensure their wellbeing.” from the report
Support with health and nutrition
Staff worked with health professionals and supported people with eating, drinking and maintaining their health.
“People were supported to maintain a healthy, balanced diet, offered regular snacks and encouraged to drink often.” from the report
Positive activities and choices
People could take part in varied activities and were encouraged to follow their interests and remain involved in everyday tasks.
“A varied activity programme was in place for people to take part in if they wished and people were positive about the activities on offer.” from the report
Risk information was not always followed
seriousA person's food preparation guidance was not known or followed by some staff. Healthcare advice about snacks and monitoring was also missing from another person's risk assessment.
“However, one person required their food to be prepared in a specific way. A risk assessment was in place; however, some staff were either not aware of or had not followed the guidance in the risk assessment which had placed the person at risk.” from the report
Medicines handling and instructions
needs fixingOne medicine was touched directly by a staff member, creating a potential contamination risk. Instructions for variable doses did not say clearly how many tablets to give or when, although this was corrected during the inspection.
“Medicines were mostly managed safely, however, one staff member directly touched the medicine causing a potential risk of it becoming contaminated and absorbed through the skin of the staff member.” from the report
Delays and gaps in records
needs fixingPeople on one wing waited up to 55 minutes for lunch. Some food and fluid records were incomplete, and the management team said improvements were needed.
“People on Munnings wing were waiting up to 55 minutes at the table before receiving their meal due to a delay in the food being brought up from the kitchen.” from the report
Quality checks did not find all problems
needs fixingAudits were in place but had not identified some of the concerns found by inspectors, including issues with food and fluid monitoring.
“Regular quality audits of the service took place to check practices were maintained to a good standard, however these could be further developed to cover areas including food and fluid monitoring as they had not been effective in identifying and addressing the concerns identified within this report.” from the report
- 01What has changed to make sure every person's risk assessment reflects the latest advice from health professionals?
- 02How do you check that staff follow instructions about food preparation and other identified risks?
- 03What checks now make sure variable-dose medicines have clear instructions and are handled safely?
- 04How have you improved food and fluid records and reduced delays in serving meals on Munnings wing?
- 05What progress has been made with end of life plans and recording people's wishes?
This was an unannounced inspection of the whole service covering all five key questions, including both the care provided and the premises. This explanation was written from the published report of 18 January 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2017
Rated Good; inspectors found kind, personalised care, but saw long waits for lunch and gaps in diabetes risk assessments.
Inspectors made an unannounced visit on 11 April 2017. They spoke with people living at the home, relatives, staff and healthcare professionals. They reviewed care records, medicines records, recruitment files, training records, complaints and quality checks.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that staff were kind, knew people well and supported their choices, health needs, activities and contact with family and friends.
There were some issues to improve. People waited too long for lunch during the visit, some diabetes risk assessments needed more information, and one medicines record had handwritten entries without the required second signature. The home had an action plan for meal experiences and said these issues would be addressed.
Kind and respectful staff
People consistently described staff as kind and caring. Inspectors saw warm, respectful interactions and staff giving people time to respond.
“All of the people we spoke to without exception told us the staff were gentle, caring and kind.” from the report
Personalised care
Care plans included people's routines, life histories, interests and preferences. Relatives and people living at the home were involved in care decisions.
“Care plans were comprehensive in detail.” from the report
Dementia support
The home used meaningful objects and activities to support people living with dementia. People could move freely around the dementia area and take part in activities suited to them.
“The environment was dementia friendly, for example no corridors or locked doors people could walk freely without coming across barriers.” from the report
Training and healthcare
Staff had training relevant to their roles and understood mental capacity and safeguarding requirements. People could access healthcare professionals when needed.
“Staff had the necessary skills to meet people's needs.” from the report
Open management
Staff said managers were approachable and supportive. The home used action plans, audits, surveys and meetings to identify improvements.
“There was a positive, open and transparent culture where the needs of the people were at the centre of how the service was run.” from the report
Long wait for lunch
needs fixingDuring the visit, people waited too long for their meals and some fell asleep at the table. The manager said meal times would be protected and audited.
“Our observation showed that people had to wait far too long for their meal and some people were falling asleep at the table.” from the report
Diabetes risk records
needs fixingSome care plans and risk assessments did not explain enough about monitoring sugary snacks and drinks for people living with diabetes. Inspectors recommended that these records be updated.
“We recommended the service update people's risk assessments that are living with diabetes to include the need for them to be monitored when consuming sugary snacks and drinks.” from the report
Handwritten medicines entries
minorSome handwritten medicines entries did not have the required second staff signature. The manager said this would be discussed with staff and checked through audits.
“We did note that on the medicines administration records (MAR) sheet when additional medication had been hand written, it was not signed by two staff members.” from the report
- 01What changes have been made to prevent people waiting too long for meals?
- 02How are people living with diabetes monitored when they have sugary snacks or drinks?
- 03How do you check that handwritten medicines entries have the required signatures?
- 04Is the manager now registered with the CQC, and what support remains in place?
- 05How many permanent staff are now employed, and how often are agency staff used?
This was an unannounced inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 27 May 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Blackbrook House
2 rated inspections over 3 years: the service has held its Good rating throughout.
- January 2020Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017
Registered with the Care Quality Commission on 6 February 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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