Barlavington Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment. People did not always receive safe support in line with professional advice and good practice guidance. Risks were not always identified and mitigated. Medicines were not always managed safely.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always ensure lessons were learnt to continually identify and embed safe practice. Systems were not always in place to identify and act on all safety concerns. Processes were not in place to analyse accidents and incidents for trends, patterns and cause. Information was not used to mitigate a further occurrence and drive service improvements.

We examined the risks of scolding following a serious incident in 2024. Following this incident safety improvements had been made to the way hot drinks were served, and this had reduced the risk of scolding from the use of teapots. However, on the 17 July we observed a further risk of scalding. The kitchen was left unattended for a period of 11 minutes whilst a large pan of soup was cooking on a gas hob. The kitchen had unrestricted access from the hall where bedrooms were located. This placed people at risk of harm from scolding or burns. When we returned on the 22 July 2025 the provider had taken action to improve kitchen safety.

We examined the risks of falls following a serious incident in 2024. Risk management processes mitigated known falls risks. However, governance processes for post falls management were not always effective in exploring cause, patterns and trends in a timely way. Information about falls was not always recorded consistently across people’s care records. There was a risk that opportunities to learn lessons from falls and act to mitigate a further occurrence could be delayed or missed.

The provider did not always work well with people and healthcare partners to ensure safe systems of care. Guidance from healthcare professionals about modified diets were not always followed. There were inconsistencies in staff knowledge, and how information was recorded across people’s care records and information boards. Kitchen staff preparing food did not show knowledge or understanding about how to modify food safely in line with national good practice guidelines. We saw on more than one occasion drinks prepared by care staff had not been thickened to the consistency assessed by a speech and language therapist (SaLT) as being safe. This meant there was a risk of people choking or aspirating because drinks and food had not been prepared in line with safe guidance. Not all people who were receiving a modified diet had been assessed by a SaLT. This meant people could not be assured their meals or drinks were being prepared in a way that was safe for them to consume. Following our feedback the provider arranged immediate training for kitchen staff and made a referral to the SaLT team for further assessment and guidance.

The provider had systems and processes in place to share important information with others, such as ambulance and hospital staff, to promote consistency in care.

The provider worked with people to protect them from the risk of abuse. Policies and procedures supported this. Safeguarding training was completed by new staff during induction and there was a system to ensure staff undertook refresher training. Staff we spoke with had an awareness of the signs indicating a person might be vulnerable to, or experienced, abuse. People told us they felt safe with the staff supporting them. A relative told us, “I am very happy with the care my Mum has. I have no concerns as to her safety or wellbeing.”

The provider did not work well with people to understand and manage risks. Risk assessments and staff practice did not ensure risks were managed safely or in a person-centred way. Care plans did not always guide staff to manage risks well. Risks had not always been considered or mitigated. We found a failure to ensure risks relating to falls, choking and the prevention of pressure ulcers were managed effectively. For example, a person’s care plan and risk assessment recorded the need for a pureed diet and 1-1 support with eating to mitigate their risk of choking. At inspection we saw the person had been given sliced banana and was eating this alone in their bedroom. There was no evidence to suggest people had been affected negatively by these failings however there was the potential for avoidable harm to occur. The registered manager told us they would address the concerns we had found and undertake a review of risk assessments.

The provider did not always detect and control potential risks in the care environment. Some staff practices had not been considered as being unsafe. On the 17 July 2025 we observed the kitchen was unattended for a period of 11 minutes whilst food was cooking on a gas hob. The kitchen had direct access into a hall where bedrooms were located. Chef knives were visible and easily accessible. An external kitchen door leading to the car park was tied open for ventilation. This provided the opportunity for people and unwanted visitors to enter or exit the care home through the kitchen without being noticed. There was also a risk of fire from the unattended naked flame. When we returned on the 22 July 2025 the provided had acted to make the area safe and had implemented measures to mitigate any further risk.

Environmental safety checks including fire, emergency lighting, legionnaires, electrics, and equipment checks were in place and tested regularly. The main part of the care home had recently been refurbished, and furnishings and carpets were in a good state of repair and free from hazards.

The provider did not always ensure safe and effective staffing. Staff received comprehensive training but had not always applied their learning to their practice. This included areas relating to health and safety, administering medicines and managing risks. This meant theknowledge and skills of some staff were not always effective in ensuring people receive safe care.

Safe employment processes protected people from the recruitment of unsuitable staff. Staff received a comprehensive induction which included mandatory training and observed practice. Staff new to care undertook the care certificate which is a set of 16 standards that forms the basis of training for health and social care support staff in England. People told us there were enough staff to meet their needs and our observations reflected this. There were plenty of staff on duty including care staff, managers and ancillary staff. People received a timely response to requests for assistance, and we saw staff taking time to sit and talk to people. A person told us, “Staff are good, and I can get what I need when I want.”

The provider assessed and managed the risk of infection. People were supported by staff who followed infection, prevention, and control (IPC) processes.Staff told us they had received training in food hygiene and IPC. They were knowledgeable about how to prevent the spread of infections and the need to use personal protective equipment (PPE) which they said was readily available to them. PPE was used appropriately throughout our visits. There was a high standard of cleanliness within the care home and the environment was free from mal odours. Visting healthcare professionals found the care home to have a high standard of cleanliness.

The provider did not always ensure safe process for managing medicines. We observed covert medicines were not administered in line with the prescribers’ instructions or medicine administration records (MAR). Medicine care plans did not provide guidance about how to safely administer the medicines covertly or check the medicine had been consumed. Between March and June 2025, trained staff had made 65 medicine administration and recording errors. Processes introduced to improve medicine safety because of these errors had failed to identify a dispensing discrepancy observed at inspection. The registered manager told us they would review medicine processes considering our feedback. There was no evidence people had been harmed from the medicine errors.

Medicines were stored in line with safety guidance including controlled drugs. People told us they had no concerns about their medicines. Feedback included, “I get my medication when I need it and have not had any problems so far” and “Staff always give me my medication it’s all fine.”