Barleycroft 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 the same. 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.

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 manager told us that they shared their vision with all staff and actively encouraged them to be part of the plan to help develop the service. They also mentioned how they conducted walk arounds on a daily basis to observe care delivered and spoke to people, relatives and the staff. Daily records were also checked to make sure they were completed correctly.

The manager said, “I observe staff practices, and interactions with [people]. I also provide feedback to staff and address any identified issues or learning, in supervision, which helps to develop a positive environment”.

Staff were very complimentary about the service and the new practices that was being put in place by the manager. A staff told us, “Everybody works well together, the communication between the team and with management works well.”

Staff were positive about the new manager and the measures that they had put in place. We saw the manager had started to build a positive relationship with people, relatives and the staff team. Staff felt that there was an open and inclusive culture within the service. Relatives were also complimentary of the service and told us that they could see positive changes within the service.

The manager told us they were available and had an open-door policy, which meant that people, families, and staff could speak to them. A relative told us, “The manager touches base with us when we visit to check all is going well.”

The manager told us they felt supported by the provider and was in regular communication with them for guidance and support. We saw evidence that the manager received appropriate training for them to be able to conduct their role effectively.

We received positive comments from staff regarding the registered manager. A staff commented, “The manager is approachable, and listens to us and they involve us with changes within the service.”

During our visit, we identified that the clinical lead lacked some information about a person’s health support needs, which meant that there could have been a potential risk that staff may not have the support and information on how to support the person correctly. This was discussed with the clinical lead line manager, and they mentioned they would talk to the clinical lead about this and support them accordingly.

A whistleblowing policy was in place, which included details on how to raise concerns both internally and externally. This allowed staff to speak up freely. Staff feedback was also sought as part of supervisions and staff meeting.

Staff were clear on how to use the whistleblowing policy and understood their role and responsibilities of reporting concerns and knew who to go to if they needed to. A staff told us, “If I see something that is not right, I will follow the whistleblowing policy. I am confident that I can inform the manager of any concerns.”

The manager told us how they had worked with staff to support the staff team to feel confident to speak up if they wanted. The manager told us, “There are various ways I check staffs’ knowledge and understanding regarding staff speaking up, for example, we discussed this in staff meetings, staff supervisions and during my morning walk arounds. I analyse staffs’ questionnaires to also get feedback too.”

We received positive feedback from the staff team, that they felt valued from the provider in regard to diversity in their workforce. The provider worked towards recruiting a workforce that reflected the religious and cultural diversity of the group of people they supported.

The manager told us the importance of embedding a positive inclusion environment by listening to people, relatives and staff as well as receiving feedback from stakeholders.

Robust good governance systems were not in place to ensure management had oversight of the home. The manager showed us their completed audits, and improvement that had been put in place to help develop the service, as well as their plans going forward to make further improvements to the service. However, the provider’s systems and processes had failed to ensure risks were always identified and mitigated on time.

For example, we identified concerns relating to 3 internal fire doors that did not close properly and an in built expansion strip within a door was missing. Although the provider was able to show that some of the actions were being completed, this was not completed immediately until we visited the service. We also found people had access to boiling water in the kitchenettes, which was a potential risk of people scalding themselves. The provider took immediate action after we informed them of this concern by installing locks on the doors.

We also identified that some vital information in peoples’ care plans and risk assessment were missing regarding their epilepsy and diabetes, which could have result in a potential risk to people if staff were not aware of their support needs and how to keep them safe from potential harm.

The above evidence shows that the provider did not have effective systems to assess, monitor and improve the quality and safety of the service.

Staff confirmed that they had regular staff meetings, which helped them to give feedback regarding improvements that where required. Records confirmed this.

Staff was positive about working for the organisation. A staff told us, “The training and induction programme is good. I find the training meets my personal development and has helped to develop my skills.”

We saw that surveys were sent out to people, relatives and staff, which helped get feedback to ensure there was a system to make improvements.

The management team had good links with a number of health and social care professionals, and this helped to ensure people’s needs were fully met.

The manager told us they worked closely in partnership with health and social professionals to ensure people received the right care and support. The manager also shared their plans with us on how they ensure joint up working continues. For example, the manager attended a number of working groups where information sharing took place and learning from other providers and professionals.

The provider shared examples with us where they have worked with other health and social care professionals to help promote people’s independence and wellbeing. We noted cases where people’s independence and outcomes improved after sustained work and encouragements by staff so people could learn to live more independently and eventually move back into the community.

Staff completed mandatory training, which helped to ensure that people received the care and support that was required to keep people safe and healthy.

The manager reviewed incidents and accidents, which the learning from them was discussed with staff in meetings. This helped lower the risk of them from re-occurring.

The provider had an improvement plan in place to help develop the service and make the relevant improvements that was required. This also included improving the environmental areas such as redecoration and refurbishment.