Bluewood Healthcare improved from Requires Improvement to Good across safe, effective, and well-led domains following a focused inspection in December 2023. The service demonstrated reliable staffing, robust safeguarding processes, and effective quality monitoring, with only a minor gap identified in medicines recording documentation.
Concerns (1)
minorMedication management: “Systems and processes for recording the administration of some medicines were not in line with guidance. We shared the good practice guidance with the registered manager.”
Strengths
· People and family members were highly complimentary of the support and care received, with consistent and reliable staffing.
· Safeguarding referrals were made to appropriate organisations in a timely manner, consistent with local safeguarding protocols.
· Staff training extended to include condition-specific topics such as dementia and epilepsy, with competency assessments including moving and handling.
· Electronic monitoring system used to track staff arrival and departure times, with office staff acting where staff were running late.
· Care plans regularly reviewed with people; equality characteristics and protected characteristics considered in care planning.
Quality-Statement breakdown (16)
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely care; supporting people to live healthier livesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staff; continuous learning and improving careGood
Focused inspection downgraded Bluewood Healthcare from Good to Requires Improvement in both Safe and Well-led, citing weaknesses in complaints handling, communication from office staff, and inconsistent care from temporary staff. Risk assessments and care plans lacked detail in some areas, though the registered manager responded swiftly to issues raised.
Concerns (9)
moderateComplaints handling: “Verbal concerns received by the service had not gone through the complaints process which meant they were not resolved.”
moderateCommunication with families: “office management staff and call staff were not always contactable, did not always listen and act on issues in relation to complaining about a small number of care staff”
moderateCare planning: “The care plan had measures in place for the type of food needed for the person but not how to encourage the person to eat. This meant the person was at risk of not having their nutritional needs met.”
moderateStaff competency: “temporary staff who provided cover were often not aware of people's needs or had not read their care plan and needed to be reminded by relatives of care needs.”
moderateMissed or late visits: “one relative who reported a staff member had not always turned up for a call at weekends... it meant a delay to the person being provided with personal care.”
moderateGovernance: “surveys were not systematically provided to relatives, which would have identified issues that needed action.”
minorInfection control: “everyone except one relative told us staff wore personal protective equipment (PPE) during the COVID-19 pandemic.”
minorIncident learning: “one had not been identified in relation to a staff member not supplying food to a person because of the staff member's own religious beliefs.”
minorCultural competency: “a staff member not supplying food to a person because of the staff member's own religious beliefs.”
Strengths
· Safe recruitment practices were in place to ensure only suitable staff worked at the service.
· People were protected against abuse, neglect and discrimination; staff demonstrated they understood how to safeguard people.
· Sufficient staffing in place according to most people and relatives.
· Registered manager acted swiftly to deal with issues when raised by inspectors.
· Registered manager understood duty of candour and worked in an open and transparent way.
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
well-led: Continuous learning and improving care; Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements