CQC report explained · a nursing home
What the CQC found at Blackmoor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found risk assessments, safeguarding procedures, safe recruitment and infection control arrangements. However, more action was needed for a known risk, and medicine stock records for three people contained errors.
- Effective?
- Good
- People’s needs were assessed before admission. Staff had training and support, people received help with food and healthcare, and mental capacity and best-interest processes were in place.
- Caring?
- Good
- People and relatives described staff as kind, caring and respectful. Inspectors observed warm interactions and found that privacy, dignity, independence and people’s choices were respected.
- Responsive?
- Requires improvement
- Care plans described people’s needs, but three people did not appear to receive their planned physiotherapy. Activities were developing, and the home still needed to improve how it met communication needs.
- Well-led?
- Requires improvement
- The home had audits and an improvement plan, and managers responded openly to inspectors. However, monitoring had not found or fixed all the problems, relatives did not always receive effective communication, and staffing consistency needed improvement.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found kind and effective care, but concerns about safety, physiotherapy, communication and management.
This was the home’s first inspection. It was unannounced and took place on 08 November 2022 and 11 November 2022. Inspectors spoke with people, relatives, staff and health professionals. They reviewed care, medicine and staff records, along with audits and other management information.
People and relatives were generally happy with the home and said staff were kind and respectful. Inspectors found good care planning, staff training, food, healthcare support and infection control. The home supported people to make choices and treated them with dignity.
There were important gaps. Medicine stock records were not always accurate. One known risk needed more action. Three people had received only one physiotherapy session in the previous month, and the home could not confirm the length of sessions. Relatives did not always receive effective communication.
The overall rating of Requires Improvement means the home was not consistently meeting the expected standard. Safe, Responsive and Well-led were rated Requires Improvement. Effective and Caring were rated Good. This was the first inspection of this newly registered service.
Kind and respectful care
People and relatives said staff were caring. Inspectors saw warm, dignified interactions and found that people’s privacy and independence were respected.
“We observed kind interactions between staff and people using the service. Staff's communication with people was warm and friendly, showing a caring attitude.” from the report
Good healthcare assessment
People’s needs were assessed before admission and care plans included health information. Health professionals said communication with the home was good.
“Referrals received from Blackmoor have been appropriate with a comprehensive history to enable effective triage and decision making on clinical prioritisation.” from the report
Staff training and support
Staff had completed core training and received extra support for people’s specific needs. Staff told inspectors they felt confident supporting people safely and effectively.
“Staff we spoke with said the training provided was good and they felt confident in their ability to support people effectively and safely.” from the report
Choice and legal safeguards
Inspectors found that people were supported to make choices, with mental capacity assessments and relevant authorisations in place.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Known risk needed more action
seriousInspectors were told about an incident involving a known risk to one person. They found that the provider needed to do more to reduce that risk.
“However, during the inspection we were made aware of an incident where the provider needed to take further action to mitigate a known risk to one person.” from the report
Medicine stock records
seriousRecords for three people did not accurately show medicine stock levels. The provider had retrained staff, but this had not yet fixed the recording problems.
“However, we found recording errors in relation to the levels of medication stock held for 3 people.” from the report
Physiotherapy was not reliably delivered
needs fixingThree people had received only one physiotherapy session during the previous month, despite having weekly programmes. The home could not confirm the length of the sessions.
“People and relatives told us people were not receiving their assessed physiotherapy support.” from the report
Relatives were not always kept informed
needs fixingA key worker system existed, but relatives did not always know who the key worker was or receive communication effectively about their family member’s care.
“However, relatives did not always know who their loved one's key worker was and did not receive communication in an effective way.” from the report
- 01What has been done since the inspection to make sure medicine stock counts are accurate every time?
- 02How are you now making sure each person receives the physiotherapy in their care plan, and how do you record the session length?
- 03What further action was taken after the incident involving a known risk to one person?
- 04Who would be my relative’s key worker, and how will you keep me regularly involved in their care?
- 05How will staffing levels remain consistent while you recruit staff and prepare to open the third unit?
This was an unannounced first inspection covering all five key questions and infection prevention and control; there were no previous ratings to carry forward. This explanation was written from the published report of 12 January 2023 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 Blackmoor
Each visit the CQC has published, newest first, back to the day the home was registered.
- January 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2021
Registered with the Care Quality Commission on 26 July 2021.
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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