Barnfield Manor Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst policies were in place to support service delivery and shared regularly with staff, there were instances in which policies had not been consistently followed. For example, shortfalls in ensuring high standards of IPC, and accurate recording of interventions and behaviours. We received assurances that these areas would be addressed.

People and relatives reflected positively on the atmosphere within the home. One relative told us, “Everybody is really patient. It’s a very calm environment; it’s got a good atmosphere.”

Staff took part in a range of events to support people to connect with their wider community, this included charity events and cultural celebrations.

Staff were motivated to provide high quality care. One staff member told us, “I treat every resident like I would treat my own family member, I like giving back to people who need care. The staff are really nice, the management are incredible, and the nursing team are great, they go above and beyond for the residents.” Another shared, “I love my job. I think I like making a difference each day.” And, “I find peace, happiness in making changes in people’s lives.”

At the time of our inspection, the manager was new in post. Whilst we found they had a clear understanding of the service priorities and were working to address some identified issues, there remained some shortalls in ensuring risks were effectively managed. For example, during a staffing observation the manager had identified staff to be extremely busy. Alongside staff feedback that staffing levels failed to consider people’s needs fully, there had been no identified actions to address this issue.

The manager was aware of their regulatory responsibilities and committed to improving standards. The manager was open and transparent throughout our inspection and responded to our feedback promptly. The manager was supported by a senior leadership team who had an active presence within the service, ensuring clear oversight and direct involvement in the day-to-day operations.

We received consistent positive feedback on leaders from people, relatives and staff. One relative told us, “I can talk to the manager. I’ve walked into their office a few times, they are accessible.” And, “I think it’s picking up really nicely, if they implement the things they intend to, it will be really nice.” Staff told us, “[Manager] wouldn’t give you anything to do that they aren’t happy to do themselves and that’s a lot better.” And, “[Manager] is visible, quiet but effective. They do walk about and are approachable.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Relevant policies and procedures were in place to support people and staff to raise concerns. Feedback confirmed staff felt confident to speak up, and the manager would listen. One staff member told us, “I think management are quick to respond to any concerns. They are open and respond well.”

The provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. During our inspection staff raised no concerns about discrimination, and relevant support and policies were in place to support a diverse workforce. One staff member told us, “It is an inclusive workplace.”

The provider had a wide range of governance systems in place to identify risk and oversee quality. However, we found effective action had not always been taken to address some of these areas. For example, whilst people’s weights were regularly reviewed, it had been identified that some people required weighing on a weekly basis for closer monitoring due to risk of malnutrition. During our inspection we found that this had not always taken place. Similarly, audits had identified gaps in recording of interventions yet effective action to address this concern had not been taken. We discussed this with leaders on site who acknowledged these shortfalls and assured us these would be addressed.

Overall, we found a structured approach to monitoring the service. This included a regular care management meeting, which reviewed people’s clinical needs, health concerns and shared risk mitigation strategies with the nursing team. A range of observations and spot checks were carried out on staff practice to ensure high standards of care were being delivered. A range of audits and reports were completed at provider level too, adding another layer of governance.

The provider understood their duty to work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People’s care records showed staff worked collaboratively with a range of professionals involved in people’s care. Referrals were made to relevant healthcare professionals where people’s health had deteriorated, and recommendations were followed.

The provider was working with relevant stakeholders to address quality issues identified through their monitoring visits.

Whilst the provider had identified areas for improvement through their own internal governance systems, some actions had not been completed or fully embedded to demonstrate sustained improvement. For example, recording of interventions or accurate completion of behaviour logs.

However, the provider had a clear, prioritised overall service improvement plan which was being worked through to improve quality and safety. At the time of our inspection, many actions were in progress, and we found this to be accurate and reflective of our findings on site. The action plan incorporated findings from own internal checks, and feedback from relevant stakeholders too. This showed a commitment to driving improvements at the service.