Date of assessment 06 August to 09 August 2024. Bluewood Care Ltd is a domiciliary care agency registered to provide personal care to people in their own homes. The service provides support to older people and younger people with a range of needs. This includes people with physical disabilities. At the time of our assessment the service supported 3 people, some of those people received 24-hour care and support. The last rating for this service was inadequate (report published 06 November 2023). We identified 2 breaches of the regulations. Conditions were imposed on the provider’s registration which required them to provide us with monthly reports on the improvements they were making to meet the regulations. We undertook this assessment to check they had followed their action plan and to confirm they now met legal requirements. This service has been in Special Measures since 06 November 2023. The provider demonstrated improvements had been made. The service is no longer rated inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
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Bluewood Care Limited was rated Inadequate overall following a focused inspection prompted by concerns about care quality and safety, with regulatory breaches found in safe care and treatment (Regulation 12) and good governance (Regulation 17), resulting in conditions being imposed. Significant failures were identified across medicines management, risk assessment, care planning, staff training competency, and governance oversight, representing a marked deterioration from the previous Good rating in 2018.
Concerns (14)
criticalMedication management: “Medicines were not handled safely or in line with the providers policy and best practice guidance. Records were not sufficiently completed to show people received their medicines as prescribed.”
criticalMedication management: “Some people were prescribed emergency first aid medicine for life threatening health conditions. These medicines were not recorded on the person's MAR and there was either no protocol for staff to follow.”
criticalCare planning: “Care records did not include an assessment of people's needs and choices completed by the provider.”
criticalCare planning: “Where a person was at risk of choking and had experienced a recent incident of choking, there was no risk management plan to inform staff of the action they should take.”
criticalGovernance: “Governance systems and processes were either not in place or were not effectively operated to monitor the quality of the service, or to drive forward improvements.”
criticalGovernance: “Care plan audits did not take place. This meant opportunities were missed to identify where improvements were needed in risk management.”
criticalIncident learning: “A safeguarding incident had resulted in a person being hospitalised. The provider had failed to ensure that suitable risk management plans were implemented to reduce the risk of reoccurrence.”
criticalStaff competency: “The registered manager and care co-ordinator confirmed to us that neither of them were qualified to deliver this training [moving and handling].”
criticalLeadership: “The provider and registered manager had failed to ensure they had sufficient oversight of the service to ensure regulatory compliance.”
moderateStaff training: “Staff training is not good, I have to train them. I'm not happy with their understanding of skin care and moving and handling skills.”
moderateStaff training: “Most staff had not undertaken up to date safeguarding training.”
moderateConsent / capacity: “One person who had a legally appointed person acting on their behalf to make important decisions had no mental capacity assessment.”
moderateSafeguarding: “The registered manager had failed to always recognise what may constitute abuse.”
moderateRecord keeping: “Reviews of people's assessed needs were not recorded which meant staff did not have up-to-date information about people's needs to ensure they received the right support.”
Strengths
· There were enough staff to provide people's planned care and people were supported by regular staff.
· Staff were recruited safely with references and completed DBS checks.
· Staff had access to PPE and used these when supporting people with personal care.
· Staff understood their responsibilities to report safeguarding concerns to the registered manager.
· Staff felt supported by management; comments included managers are approachable and supportive.
Quality-Statement breakdown (14)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Using medicines safelyInadequate
safe: Preventing and controlling infectionRequires improvement
safe: Learning lessons when things go wrongInadequate
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Staffing and recruitmentGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; consent and MCARequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
well-led: Managers and staff being clear about their roles; quality performance, risks and regulatory requirementsInadequate
well-led: Working in partnership with othersRequires improvement
well-led: Engaging and involving people; continuous learning and improving careRequires improvement