Bluefield Care Services deteriorated from Good to Requires Improvement, with three regulatory breaches identified across safe care and treatment, staffing, and governance. Key failures included persistent late and missed visits, unsafe medication administration, failure to notify CQC and local authority of incidents, and ineffective governance and audit systems that did not identify or address these shortfalls.
Concerns (12)
criticalMissed or late visits: “"There are times when [care staff] are very, very late. 9am and they get here at 11am"; "Multiple carers. In 2 to 3 days, we get 3 or 5 different carers"”
criticalMedication management: “MAR charts and daily observation records of 1 person showed they received their medicines within 2 minutes of each other. One of the medicines is required to be given half an hour before any other medicines.”
criticalGovernance: “The provider's systems or processes were not established and operated effectively to monitor and improve the quality and safety of the service.”
criticalSafeguarding: “The registered manager did not share concerns about a person at risk of financial abuse to the local authority that had been highlighted by care staff.”
criticalIncident learning: “The provider did not notify CQC of all incidents that affect the health, safety and welfare of people who use services.”
moderateSupervision / appraisal: “Supervision records where sometimes very brief and follow up actions were not consistently followed through... Not all staff received an appraisal of their performance.”
moderateStaff training: “There was no evidence of training on topics specific to people's individual needs such as Parkinsons, disease, dementia, diabetes, or catheter care.”
moderateRecord keeping: “Some care records were not dated or signed for... not every audit had a signature, name, and role of auditor. A few of the records written by care staff were hard to read.”
moderateStaffing levels: “People and their relatives provided mostly negative feedback about staffing levels and the consistency of care staff allocated to them.”
moderateComplaints handling: “"I have complained twice, phoned them 12 times in 10 months about the timing of visits." They felt the provider did not always listen and respond to their concerns in a timely manner.”
minorCommunication with families: “"No communication unless we contact them." Some relatives did not agree with the information completed by staff on their daily visits.”
minorStaff competency: “Some of the people using the service told us they found it difficult to communicate with some care staff for whom English was a second language.”
Strengths
· People were protected from the risk of abuse; staff trained in safeguarding and knew how to identify and report abuse
· Safe recruitment practices in place including DBS checks, employment history, and two references
· People's dignity, privacy and independence were upheld and respected by staff
· People were supported to access healthcare services and staff worked closely with GPs and other professionals
· Risk assessments undertaken and support plans put in place to guide safe care delivery
Quality-Statement breakdown (25)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Infection controlGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standardsGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives and access healthcare servicesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisionsGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to maintain relationships and take part in activitiesGood
responsive: End of life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Continuous learning and improving careRequires improvement
well-led: Managers and staff being clear about their roles and understanding quality performance and risksRequires improvement
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement