Blackberry Hill

People’s rights under the Mental Capacity Act were not fully upheld. Where people lacked the capacity to consent, the provider did not always work in accordance with the law and current best practice guidelines.

People lived in a home where regular checks were not always completed to ensure the safety of the environment. During the inspection we also identified concerns relating to fire safety and staffing that placed people at risk. Significant findings identified during a fire risk assessment had not all been actioned. The provider gave assurances during the assessment that action was being taken to address the shortfalls. We also raised these concerns with the local fire service.

People had their needs assessed when they moved to the home. Care plans were developed using these assessments. Improvements were needed to ensure care plans and risk assessments reflected people’s current needs.

Governance arrangements were not effective and did not ensure risks were consistently identified or addressed. A series of checks and audits were completed, but these had not been effective in monitoring quality or driving improvement. The registered manager was responsive to feedback. Some improvements had been completed before the end of the assessment.

We found a breach of regulations concerning governance. The provider took some immediate action during the inspection, but governance systems were not robust enough to provide ongoing assurance. We have asked the provider for an action plan in response to some of the concerns found at this assessment.

Medicines were managed well and staff worked with agencies involved in people’s care. Staff felt supported and were treated equally.

Staff worked well with health professionals, ensured timely access to healthcare, and supported people to lead active, fulfilling lives.

People experienced caring and compassionate support, and staff promoted choice, communication and meaningful activity. People were treated with dignity and respect, and relatives consistently reported that their family members had a good quality of life.