Barton Brook Care Home

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 requires improvement. At this assessment the rating has remained 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.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice. Since our last assessment there had been a deterioration in the learning culture across the home. The provider had failed to act on previous learning from risks already known to them. For example, learning from risks associated with falls management and the safe management of medicines.

Whilst we acknowledged the provider had a new leadership structure in place, further time was needed to ensure new systems and processes were fully embedded and improvements sustained.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had made improvements in respect of prospective new placements into the home. Pre-admission assessments were now managed and overseen by the providers internal multidisciplinary team made up of clinical expertise with input from the interim home manager. This new system appeared to be working well, and we saw examples where potential new admissions had been refused that might otherwise have been accepted under previous management regimes. Additionally, the provider had committed to the recruitment of a clinical nurse lead. This role would complement existing structures and should enable better management and oversight of clinical risk.

The provider had not always work well with people and external partners to understand what being safe meant to them and how to achieve that.

As part of the providers service improvements plan, work had taken place to address shortfalls previously identified around safeguarding. For example, failures to identify safeguarding concerns in a timely manner and the involvement of all staff to ensure safeguarding was everyone’s business. Further time was required to ensure newly established systems and processes were properly embedded and improvements sustained.

Whilst staff were aware of the deprivation of liberty safeguards (DoLS) and how this impacted on care, they were less familiar with any conditions that might be attached to DoLS and what to do to ensure people’s rights were protected or help lessen the restrictions in place.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive.

We looked at the management of emergencies and how staff would respond. Unit managers (nurses or senior care assistants) had responsibility for the day-to-day safety and welfare of people on their respective units. However, the provider had failed to ensure such staff had completed properly accredited first-aid training. In response to an incident in April 2025, the provider had retrospectively provided first-aid training to staff, but at the time of this assessment, several unit managers had still not completed their training. This meant in the event of incidents such as unwitnessed falls, staff were not equipped to effectively assess for potential injuries.

The provider detected and controlled potential risks in the care environment. This included risks associated with fire and gas and electrical safety. Relevant checks were completed by competent people and records and certification was properly maintained and in order.

The provider did not always make sure the right skilled and experienced staff were deployed to meet people’s needs. They did not always make sure staff received effective support, supervision.

Without exception, the stand-out theme from our discussions with people, their relatives and staff was staffing levels. We found the provider placed great emphasis on data from the dependency tool used to assess staffing levels versus people’s dependency. However, the tool did not take account of the layout and complexity of the buildings and premises, or how effectively staff were supervised deployed on any given shift. Comments from people included, “I feel they are understaffed, that’s the main thing” and “The staff are lovely but just too rushed and preoccupied.”

On Monton unit, we observed several residents freely walking into the bedrooms of other residents who were being cared for in bed. A member of the inspection team had to guide one person out of another person’s bedroom, as they were attempting to remove the bed clothes of the person who was in bed. We also observed 10 people left unsupervised for a period of time in the communal lounge, this was because care staff had not been effectively coordinated and had been deployed to provide personal care to people in their rooms all at the same time. Comments from staff included, “The majority of residents, especially those with high nursing needs, require two staff to provide care. The numbers of staff just don’t seem to stack up” and “I don’t know if we’re actually ‘short staffed’ or if it’s just the way things are organised. It often feels disorganised.”

We raised our concerns with the provider about the deployment and supervision of staff across the home, but particularly on Monton Unit. The provider responded by putting an experienced unit manager in place and strengthening leadership and supervision of staff in this area.

The provider had not always assessed or managed the risk of infection effectively. Aspects of infection, prevention and control (IPC) formed part of the providers ongoing improvement plan for Barton Brook. At this assessment we found some of areas of the home to be visibly unclean with a malodour. For example, on Brindley unit, the floor in communal areas was sticky, a glass fronted notice board was covered in food spalts, and in the tea making area the rubbish bin was overflowing. One relative commented, “I don’t think there are enough domestic staff to cope with the demands of a 24-hour care facility."

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

When people were prescribed medicines to be taken ‘when required’ (known as PRN protocols) to support their administration did not contain personalised information that was detailed enough to ensure they were administered safely and consistently. For example, PRN protocols for different types of laxatives contained identical information and had not been personalised reflecting the individual needs for those people items were prescribed for.

Staff had access to a digital tool to enable the assessment of people’s pain levels if they were unable to communicate their pain levels to staff. However, staff did not consistently use the tool which meant people may not have be given their pain relief when it was needed. When medicines were prescribed with a variable dose there was no information for staff to follow to ensure the most appropriate dose was selected.

Medicines were stored unsafely. The temperatures of the medicine rooms were much higher than recommended by the manufacturers. Senior management had been aware of the concerns for 2 months, but no action had been taken until after the inspection visit. Records about fridge temperatures were made sporadically which meant it was not possible to tell if medicines stored in the fridge had been stored safely.

Medicines records and stock levels demonstrated that medicines were properly accounted for which meant the records accurately reflected the medicines people were given.

We found no evidence that people were harmed at the time of the assessment because the harm is not always immediate. However, people were placed at increased risk of harm by not managing medicines safely.

Some people needed to be given their medicines covertly, by hiding the medicines in food or drinks. Information from a healthcare professional about how to do this safely was not always available. There was no practical information for staff, including agency staff to follow about how to disguise medicine in line with pharmacy advice and people’s personal food and drink preferences.

When people were prescribed thickener to be added to their fluids, to help them swallow the fluids safely, we found the records did not always show they had been thickened. We also found there were no records to show that people’s liquid medicines had been thickened prior to administration.