Barlavington Manor

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 good. At this assessment, the rating has changed to 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.

The service was in breach of legal regulation in relation to governance at the service. Governance processes were not effective in identifying some service shortfalls. There was not an adequate process for assessing and monitoring the quality of the service. Lessons were not always learnt to drive service improvements.

This service scored 57 (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 had a shared vision which embodied the culture and values of their workforce and organisation. The registered manager told us the values of the home and expectations of staff to uphold these were covered during staff induction and within the staff handbook, team meetings, and staff supervision. However, during the inspection, we observed some staff did not always apply these values to their practice and we told the registered manager about this. People had a copy of the resident’s charter, and this was displayed around the home. This outlined people’s rights and their expectation to be treated with dignity, respect, and autonomy and what to do if this was not their experience.

The provider and registered manager understood the context in which they delivered care and did so with integrity, openness, and honesty. However, records showed concerns had not always been reported to the appropriate local authority or organisation. This meant we could not be assured the health, safety and wellbeing of people was being appropriately monitored to prevent harm and improve care. We signposted the registered manager to CQC regulatory processes and West Sussex safeguarding guidance. The provider and registered manager were responsive to our feedback and recognised that improvements were needed.

The provider, people, visitors, and health professionals all spoke warmly and positively about the registered manager. They told us the registered manager was passionate about ensuring the service delivered quality care to meet people's needs. We observed people knew who the registered manager was, and interactions were, friendly, warm, and positive. Staff told us they felt supported by the registered manager. A member of staff described them as, “The most amazing person. She is the heart and soul of Barlavington.” Another said, “[Name] is the most caring and kind person. Their passion and commitment to residents and staff is second to none.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff knew what processes supported them to raise concerns within their organisation and with partners agencies. Processes were in place to speak up anonymously or with additional independent support such as an advocate. Staff were encouraged to share new ideas and be curious about things. They used team meetings and 1-1 supervision meetings to do this. Policies and procedures provided people, staff, and visitors the opportunity to feedback about their experiences of the service. The manager promoted an open-door approach, so that people using the service, staff and relatives were able to raise queries or issues with the management team. Openness of conversation was encouraged, and feedback was used to improve the service.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff uniqueness, diversity and ethnicity were embraced within the team. Staff told us their individuality was supported by the organisation and were treated fairly. Relevant legislation and best practice guidance was implemented to ensure staff were treated in a fair and equitable manner. Recruitment processes supported fair employment opportunities.

The provider did not have effective governance systems to assess, monitor and drive improvement in the quality and safety of the service. There was a failure to ensure clear responsibilities, roles or systems of accountability to ensure good governance.

The provider and registered manager did not have effective oversight of quality monitoring or audits. This had led to a failure to recognise the inconsistencies we identified in how risks to people were being managed. This included the risk of choking and the failure by staff to follow professional guidance. Quality assurance checks were undertaken by a designated member of staff; however, these were more of a check list than an audit. They lacked detail and did not identify actions or monitor outcomes. There was no evidence of registered manager oversight, analysis or action. Quality assurance processes had not identified inconsistent recording across people’s care records or the failure to report events in line with requirements. Quality checks had not considered person-centred approaches to care planning. This meant a failure to recognise some care records were task focused and did not reflect people’s involvement, preferences or voice.

There was evidence of registered manager oversight of medicine errors and provider led action. However, medicine audits had failed to identify issues with covert medicines, prescription labels and prescribed drink thickeners. The provider and registered manager were responsive to our feedback and said they would act to improve governance processes.

The provider was aware of the challenges with operating the service within a rural location. Their business continuity plan considered areas such as staffing, adverse weather and information technology (IT) system failures to ensure the service could continue to operate safely and effectively.

The provider understood their duty to collaborate and work in partnership, so services worked together for people. The registered manager attended professional forums and joined network and information groups. Information was shared through team meetings. The service worked in partnership with other professionals and community groups. People were encouraged to form community connections such as local clubs and were involved in running community engagement and fundraising events at Barlavington Manor. Records showed healthcare professionals regularly visited the service including GP’s, District Nurses, and the Chiropodist. This ensured people’s health needs were assessed and met.

The provider did not always demonstrate continuous learning, innovation, and improvement. The provider had not ensured their knowledge, about how care should be delivered was up to date and reflected regulatory requirements and best practice guidance. A lack of up-to-date knowledge could lead to unsafe practices and a failure to provide good person centred care.

Processes did not always actively contribute to improving people’s experiences and service improvements. Events such as accidents, incidents and falls had not always been robustly investigated to learn lessons and support change. Learning from previous incidents had not always been implemented effectively to improve people’s care experiences.

Staff told us they were encouraged to share their ideas for improvement and innovation. They understood their responsibility to be open in the event of anything going wrong and were supported to learn from any mistakes.