Barleycroft 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 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 health and safety at the service.

This service scored 62 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We saw accidents and incidents were recorded on an electronic system. These were reviewed by the manager to identify any action required to prevent a potential recurrence.

There were learning from incidents and the outcome of investigations were discussed with staff during handovers or staff meetings.

There were procedures for staff to follow in an emergency. For example, if a person using the service had a fall and hit their head.

We advised the provider to update their policies and procedures regarding head injury as this information was not in the policy to ensure medical advice was sought immediately if a person had a fall and hit their head and was on blood thinning medicine. An updated copy was sent to us following our inspection.

There was an on-call system in place where a member of the management team was available if staff needed advice in an emergency.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

There were appropriate transition systems in place for when people moved into the service. People’s needs were assessed before they moved to the service. The needs assessment contained information about the person’s medical, physical, background history and the care and support they required. This enabled the provider to determine if they could meet people’s individual needs effectively. Information was gathered from a variety of sources such as social workers, health professionals, and family members. This helped to ensure staff were able to meet the person’s needs safely.

The provider had safeguarding systems in place to protect people from the risk of abuse. The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The provider shared concerns promptly and appropriately.

People told us they felt safe at the service. A person told us, “Yes, I am definitely safe here and the staff look after [person] well.” A relative told us, “My [family member] is safe and staff treat them well.”

Staff had completed training in safeguarding people. They were able to tell us how they would recognise signs of abuse and poor practice and how to report them. The service had policies and procedures for safeguarding adults and staff were aware of them. Staff had knowledge on how to recognise and report signs of abuse. They understood how to protect people from the risk of abuse and had clear understanding of safeguarding procedures.

Staff were aware of their role and responsibilities in raising concerns with the management team and the role of external agencies.

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, supportive and enabled people to do the things that mattered to them.

We found that systems were not always in place to effectively assess and manage risks to people while they received a service. During this assessment, we found not all risks about people’s safety were assessed to ensure they were supported to remain as safe as possible.

For example, we found one person had a medical condition which could cause them harm to their health. There was no risk assessment to cover this area or actions to be taken if the person became unwell.

We also found other risk assessments were not comprehensive and did not give details of all the actions staff needed to take to mitigate the risks to people. For example, where people were at risk of having seizures and there was not clear guidance of when staff needed to call for an ambulance. Therefore, people were at risk of receiving unsafe care and support, as staff did not have appropriate guidance to follow to reduce risks to people.

Systems were not always effective in assessing and managing risks to people while they receive a service. This placed people at risk of harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

On the day of our visit we noted that three fire doors in the service were not closing fully. This put people, staff and visitors to the service at risk in the event of a fire. The doors were adjusted on the day of the inspection in order for them to close properly.

We discussed our concerns with the manager, and they told us the provider had made arrangement for an external contractor to come and check all the fire doors and fix them to ensure they close properly. We explained that in the meantime, the provider needed to ensure people and visitors to the service remained safe.

We also noted during our walkaround that people were at risk of being scalded from boiling water from the dispenser in the kitchenettes which people had access to. Again, we discussed our concerns with the manager and asked them to take immediate actions to ensure people were safe especially people with sensory loss. There was also an item stored on top of one of the water dispensers which meant there was a risk that staff or people could lean over the boiler to reach the item, which was a potential risk. Systems were not robust enough to demonstrate safety was effectively managed.

There were checks being carried out by different staff within the service. However, we reminded the provider that all staff had a duty to take reasonable care of their own safety as well as the safety of people and visitors.

The provider made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff employed by the service to ensure the needs of people were met and they were supported safely. People were supported by the same staff team to help give continuity of care. The provider explained staffing numbers were determined by the needs of people and their routines. For example, some people had the support of staff on a one to one basis due to their needs.

People and their relatives felt there were enough staff working at the service. Relatives told us there were staff around when they visited, and their family members could call for help from staff as needed and staff responded accordingly.

The provider had an effective recruitment procedure to ensure suitably qualified and experienced staff were employed. We found relevant checks had been completed before staff worked at the service. Staff files contained application forms, copies of passport or driving licence, references, health checks and criminal records checks. This helped to ensure people who used the service were not exposed to staff that were barred from caring for vulnerable people.

People and their relatives felt staff had the knowledge and skills to look after people who used the service. A person said, “Yes, the staff are very good and caring.” A relative told us, “The staff care for [person] in a caring way .”

People were supported by staff who had the knowledge and skills required to meet their needs. Staff received appropriate training and professional development. They were trained in areas such as moving and handling, first aid, food hygiene to ensure they were competent in their role.

Staff received an induction when they started work for the service. This covered a number of areas including training and familiarising themselves with policies and procedures and getting to know people who used the service.

Staff received appropriate supervision and support, which helped to ensure they were able to provide effective care. Staff told us they felt supported in their roles. We saw copies of staff supervision records and noted a range of issues were discussed, including staff training needs.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Relatives told us the service looked clean when they visited. There was no unpleasant smell on any of the floors. The provider policies and procedures to prevent and control infection within the service.

Staff were provided with personal protective equipment such as aprons, masks, and gloves. They were trained in using safe practices and ways of working to prevent or reduce infections. Staff ensured the environment was clean and safe for people.

Prior to our inspection, we had received information that there was an infestation of mice in the service. During our visit we did not see any mice and there were still traps around the service. The provider informed us that the infestation had been addressed, and 2 external companies continued to monitor the situation.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff involved people in planning, including when changes happened with their medicines.

People told us staff helped them to take their medicines at the correct time and as prescribed. They were happy with the arrangements and told us they had no concerns. A person said, “The staff give me my medicines when they are due.”

We found people were supported with their medicines in a safe way by staff who had been appropriately trained. There were medicines policy and procedures in place for staff to follow when supporting people with their medicines.

People had electronic medicines administration records (MAR) in place. Staff recorded when people had taken their medicines. We saw the MAR records were completed accurately when staff had administered medicines to people and there were no missing signatures. Medicines were stored in a locked trolley and were accessible to only staff responsible for administering.

The regional support manager regularly audited the medicines records to ensure they were completed correctly and to make sure that people received their medicines when they needed them.
There was guidance for staff to follow where people had been prescribed PRN [when required] medicines such as pain killers or medicines for other health conditions.