Barnfield Manor Care Home

Updated 13 November 2025

Date of assessment: 24 November to 2 December 2025. The service is a nursing home providing support to adults, some of whom live with dementia. The service is registered to support up to 39 people. At the time of our inspection, 27 people were living at the service.

This inspection was carried out in response to information of concern received.

The provider was in breach of legal regulation relating to staffing at the service.

Staff were not deployed effectively, for example we observed staff were rushed during mealtimes. Systems to calculate staffing levels did not consider factors such as falls risk, or layout of the building impacting on response time, staff feeling stretched and increased the risk of harm.

Recording of care interventions, such as fluid monitoring were not always completed to show people had received care in line with their assessed needs. Analysis of behaviour related incidents was not always accurately completed. Some care plans and risk assessments did not contain sufficient guidance to support people’s identified risks safely. During our inspection we observed some infection, prevention and control (IPC) and environmental risks, including overflowing bins and presence of malodours. A range of audits and checks were in place, however effective action to address identified risk was not always taken.

Falls were managed safely, and a root cause analysis was completed and learning was shared to mitigate ongoing risks. People were protected from the risk of abuse as staff knew how to recognise, and report concerns about abuse. The provider was updating the environment and décor with people living at the service to ensure it met their needs and preferences. Care plans and risk assessments were in the process of being updated and reviewed with people and their families. The provider managed medicines safely.

A new manager in post was committed to driving improvement, and was working through a clear service improvement plan. Staff felt supported and fed back that Barnfield Manor Care Home was an inclusive workplace. The provider was working in partnership with a range of stakeholders to address quality issues, and improve outcomes for people.

Updated 13 November 2025

People and relatives did not always feel there were enough staff to meet their needs promptly, telling us sometimes they had to wait for support. We were told that involvement in care planning varied, but were assured plans were in place to improve this. We observed some instances where transitions into the service could have been managed in a more person centred way to ensure people were comfortable and their dignity maintained.

People and relatives felt safe using the service and that any concerns would be listened to and acted on. People spoke highly of the staff caring for them and were observed to be comfortable in their presence. We observed safe practice carried out by staff, such as moving and handling manoeuvres. People and relatives reflected positively on the atmosphere and culture within the service and were confident in the leadership.