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Inspection Summary

Overall summary & rating

Requires improvement

Updated 20 September 2018

Barnham Manor is a 'care home.' People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Barnham Manor is a home owned by Barnham Manor Limited. Barnham Manor is the only home under this provider.

Barnham Manor is a nursing home registered to provide accommodation, nursing and personal care for up to 33 older persons. At the time of the inspection 32 people lived at the service. The inspection took place on 17 May 2018 and was unannounced.

There were 28 single bedrooms and three shared bedrooms. All bedrooms had an ensuite wet- room bathroom. The home had a lounge - dining room which people were observed using. There were also areas where people and visitors could sit such as recess areas on the first floor. There were well-maintained gardens at the rear which people enjoyed using. A passenger lift was provided so people could have level access the first floor.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The home was last inspected on 14 June 2016 when we identified a breach of Regulation because the provider had not ensured service user's care records were secure. A requirement was made for this and the provider sent an action plan to say how this was being addressed. At the inspection undertaken on the 17 May 2018, we found action had been taken to improve and secure people’s care records appropriately.

At our last inspection we rated the home as good. At this inspection we found that evidence demonstrated that the service required improvement in some areas.

The provider had failed to adequately assess, and mitigate the risks associated with the safe evacuation of people from the service in the event of an emergency. The provider had not developed personal evacuation plans (PEEPS) for people. These are plans that detail the individual support people would need in the event of an emergency. Many people had different levels of mobility and required the support of staff and equipment to transfer and mobilise.

Although risks associated with people’s mobility had been assessed and recorded, we identified that the manager was not always responsive in reviewing and following up incidents when people had suffered falls.

The provider did not always have a framework in place to ensure quality performance, risks and regulatory requirements were managed.

The provider did not have a consistent approach to involve and engage people who use the service to be involved in their care.

People’s needs had been assessed and care plans developed to reflect these. However, people’s care was not always delivered in a personalised way that met their needs and preferences.

People and their relatives spoke highly of the staff and said they felt safe living at the home. Staff understood their responsibilities to keep people safe. Staff were trained in safeguarding processes and demonstrated understanding of what to do if they considered people were at risk of harm or if they needed to report any suspected abuse. Staff worked together effectively and across organisations to deliver effective support.

Staff recruitment procedures ensured only those staff suitable to work in a care setting were employed. Staff were well trained and were able to meet the care and support needs of people. There were enough suitable staff on duty to care for people. One relative told us, “I think there are sufficient staff. They work very efficiently and Mum has never complained of having to wait if she needs anyone.”

Staff understood their responsibilities regardin

Inspection areas


Requires improvement

Updated 20 September 2018

The service was not always safe.

Risks to people’s safety were not always properly assessed and mitigated. Personal Evacuation Plans were not in place to ensure the safety of people in the event of an emergency or fire.

Systems and processes were in place to safeguard people from abuse.

The service had sufficient staff to support people to stay safe.

Medicines were well managed and administered safely.

People were protected by safe infection control measures, which included audits, cleaning schedules and the correct protective equipment worn by staff when required.

Lessons had not always been learned when things went wrong.



Updated 20 September 2018

The service remained effective.

People’s needs and choices had been assessed.

Staff received the training they needed to give good support.

People were supported to eat and drink enough to maintain a balanced diet.

Staff worked well together and with other organisations.

People's needs and personalised choices were assessed by staff that knew people's individual preferences well.

People had timely access to healthcare when they needed it and staff supported them receive the care and treatment

Staff had a good understanding of the Mental Capacity Act 2005 and the service was meeting the requirements of the Deprivation of Liberty Safeguards.


Requires improvement

Updated 20 September 2018

The service was not always caring.

Although staff had a good understanding of people’s needs, people’s care was not always delivered to reflect their personal choices.

Staff supported people in a compassionate and kind way whilst respecting people’s privacy and dignity.

People’s independence was not always promoted to reflect their needs and choices.


Requires improvement

Updated 20 September 2018

The service was not always responsive.

People’s care was not always delivered in a personalised way that met their needs and preferences.

Complaints, when received, were addressed appropriately and actions were taken to improve the quality of service delivery to people as a result.

People were supported professionally and compassionately at the end of their lives.


Requires improvement

Updated 20 September 2018

The service was not always well-led.

The registered manager had failed to assess and implement personal evacuation plans to ensure the safety of people in the event of an emergency.

Systems were not always in place to ensure that actions were taken following falls and incidents.

Staff felt well supported by an approachable and transparent registered manager.

People and relatives felt that the registered manager was open and proactive in the running of the home.

Staff at the home worked well with external agencies.