Blackwater Mill care home, which was placed into Special Measures by the CQC last autumn, will be closing at the end of this month, after it was revealed, among other things, that allegations of sexual abuse had not been investigated.
After being placed in Special Measures in October 2024, just two months later, the CQC imposed further urgent conditions on Blackwater Mill Residential Home, restricting admissions and re-admissions to the service.
Buckland Care Limited, who run the residential care home, had lodged an appeal with the CQC against the rating, saying that most issues raised in the report from the inspection last year had already been resolved. However, in light of new information, they’ve now withdrawn that appeal and decided to close the home instead.
Extent of failings now evident
The extent of the further failings have now been made public in a Care Quality Commission (CQC) report published this week.
The report highlights many breaches of regulations, including safeguarding, safe care and treatment, staffing, fit and proper persons employed and duty of candour. The breach relating to duty of candour (openness) is new, while the remaining breaches have been persistent issues identified in previous inspections.
Serious safeguarding failings
The report highlighted incidents of potential sexual abuse that were not properly investigated, with no evidence of action taken to prevent future occurrences. The home failed to notify relevant authorities, including the CQC and local safeguarding teams, about serious incidents.
Although some relatives felt their loved ones were safe, others expressed serious concerns. Incidents of neglect and organisational abuse were observed, including people receiving their prescribed medication hours later than scheduled and being left alone in unsafe conditions.
Residents who required supervision when eating due to choking risks were found unattended, eating with their hands and at risk of harm. In one case, a person assessed as needing assistance with eating was left in bed with cold porridge and no cutlery. Staff were also seen attempting to feed residents who were not fully awake, causing distress and increasing the risk of choking.
“The well-being of our residents has always been our highest priority”
A spokesperson for Buckland Care Limited, who ran the care home told OnTheWight,
“We acknowledge the findings of the recent Care Quality Commission (CQC) inspection and recognise the concerns raised regarding Blackwater Mill Residential Home.
“The well-being of our residents has always been our highest priority, and we have worked closely with the local authority and CQC to address key areas, including staffing, training, and care planning. While significant efforts have been made, after careful consideration, we made the difficult decision to withdraw our appeal and proceed with the planned closure of the home.
“Our focus throughout this process has been ensuring a smooth and supportive transition for residents, working alongside families, local authorities, and health professionals to help each individual find a new home that best meets their needs. We are pleased that suitable alternative placements have been secured, ensuring continuity of care for all residents.
“We also want to extend our sincere appreciation to our dedicated staff for their commitment and compassion. Many team members have already secured new roles within the care sector, and we continue to support those still seeking employment.
“We understand that this has been a challenging time for residents, families, and staff, and we remain committed to providing ongoing support to ensure a positive transition for all.”
Failure to learn from incidents
The CQC report also highlights that the provider was found to have ineffective systems and processes for learning from safety events. Incidents and accidents were not always reported appropriately, and there was no clear evidence of action taken to improve care following such events.
Risks to residents’ health and wellbeing were not consistently identified, and staff did not always have access to clear or accurate guidance on how to mitigate these risks. The safeguarding systems were deemed ineffective, leaving residents at risk of avoidable harm.
Concerns over staffing and training
The inspection found that the provider did not ensure staff had the necessary skills, knowledge, and training to meet residents’ needs. Recruitment practices did not meet legal requirements, raising concerns about the suitability of new staff.
Additionally, the home was found to be understaffed, which impacted the quality of care. Inspectors observed staff struggling to meet basic care needs, including personal hygiene and repositioning residents. The high turnover of staff was also noted as a concern, with relatives reporting a lack of continuity in care.
Poor infection control and hygiene standards
The inspection found serious failings in infection prevention and control. Inspectors observed visibly unclean floors, toilets and corridors, with some areas having strong odours of urine. Some bedrooms were described as malodorous (foul-smelling), with staff providing unsatisfactory explanations for the issues.
Staff were seen handling soiled items without wearing appropriate personal protective equipment (PPE), increasing the risk of infection. Hand hygiene practices were also inadequate, and cleaning schedules were not always followed.
Unsafe medication practices
Medicines were not managed safely, with residents not always receiving their prescribed medication. Some medicines were unavailable, and records showed that on multiple occasions, medication was not given because residents were asleep or refused, without follow-up or review.
Fridge temperature records indicated that medicines were stored outside the recommended temperature range, but no action had been taken to address this. Controlled drug records also contained discrepancies, which were only resolved after inspectors raised concerns.
Environmental safety risks
The home was found to have multiple safety hazards. Bathrooms lacked emergency alarm pulls, placing residents at risk if they fell. Some call bells were out of reach, and movement alert equipment was not being used correctly.
The fire risk assessment was found to be inadequate. Fire doors had been compromised, and staff did not demonstrate a clear understanding of evacuation procedures. There was also evidence that previous fire safety concerns raised by inspectors had not been addressed.
Legionella risks were identified due to blocked sinks and standing water in some areas. Electrical hazards were also noted, including overloaded extension leads and exposed wiring in bedrooms.
Lack of action from management
The CQC report concludes that Blackwater Mill care home has consistently failed to address previous concerns. Despite repeated inspections highlighting serious issues, the home has not made the necessary improvements to ensure residents receive safe and appropriate care.
Due to the severity of the findings, the local authority has been providing additional oversight and staffing since November 2024.
Suitable alternative placements have been secured for all residents and many staff members have already found new work elsewhere.
