Barton Lodge

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. This is the first assessment for this newly registered service. This key question has been rated 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 people’s safe care and treatment.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety. The provider did not have effective systems to manage and respond to safety alerts and medicine recalls, this meant safety alerts could be missed, placing people at risk. However, when things went wrong, the service had systems in place to cascade learning from these events to the wider staff team and across the organisation. Staff told us they attended regular meetings where learning lessons was a regular item for discussion.

The service 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 service had a clear admissions process in place which included a face-to-face assessment by a member of the management team. Staff told us they received all required information from health professionals prior to people moving into the service. Relatives told us people were able to access other healthcare service as needed. One relative told us, “[Person] receives home visits from their GP and Parkinson’s nurse.” Another relative said, “[Staff] sit with [person] (to support them) during the video conferences with GP and consultants.”

The service did not always share concerns quickly and appropriately. For example, we found one person had raised concerns and a separate complaint had been raised and this was investigated by the service. However, this was not escalated to the local authority safeguarding team for independent review. Staff understood their responsibilities in relation to keeping people safe and felt confident to raise these with the registered manager. One staff member said, “Any concerns, I would go straight to the manager and can go to their manager if I am not satisfied with the response.”

The service did not always work well with people to understand and manage risks. They 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.  Care plans and risk assessments did not always contain consistent or enough information on how staff should support people to manage risks specific to them. For example, one person’s care plan contained conflicting information about their level of mobility and what equipment was required to support them safely. This increased health and safety risks to people as staff did not always have information and guidance available to meet people’s needs safely. Despite our findings, people and relatives told us they felt safe. One person said, “I feel safe here, they check on us at night.” A relative told us, “[Relative] is happy [at Barton Lodge]. They get good care. They feel safe because people are always around.”

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care.  For example, equipment servicing records were not available at the start of our assessment. This meant the service could not be assured equipment was safe to use. We found substances hazardous to health were easily accessible in communal areas, with lockable doors left unsecured. The service responded promptly to our concerns and servicing records were in place by the end of our assessment. People and their relatives were generally happy with the environment. One person told us, “I have a nice bedroom with a shower.” A relative said, “The dining room and living room are beautifully decorated.”

The service did not always make sure there were enough qualified, skilled and experienced staff. We received mixed feedback about staffing levels in the service. One person told us, “I have no worries, everybody is kind. I press the bell, and they come quite quickly.” A relative said, “[Relative] is very well looked after here. I am happy with the numbers of staff, they are brilliant here.” However, another said, “I would like to see more staff at weekends, sometimes I come in at weekends and don’t see anyone.” Another relative told us, “They come very quickly during the day but sometimes [relative] has to wait longer on the weekends. I think the reason is less staff but it is normal.” We spoke with the registered manager who told us they had increased staffing in areas of the service following recent feedback. Staff rotas confirmed this. During our visits, we observed call bells were responded to promptly. Staff were recruited safely and received effective support, supervision and development.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We found expired food items in communal fridges which had not been identified by staff. This placed people at risk of food borne illnesses. The service disposed of these items and put additional checks in place after we raised this with them. However, we observed the service was clean with no malodours. Staff had access to and wore appropriate personal protective equipment as needed. People told us the service was cleaned regularly. One person told us, “They come in every day to clean.” A relative said, “I am happy with the cleanliness, there are never any offensive smells.”

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. On the first day of our inspection, we observed people did not receive their medicines in a timely way, as directed by the prescriber. Therefore, there was a risk people may not get the therapeutic benefits of the medicines or could experience adverse effects. We raised this with the provider who told us the covering nurse was unfamiliar with the medicines round as they were coving at short notice and usually worked night shifts. The provider had not put any additional resources in place to mitigate this risk. Used or unwanted controlled drugs were not always correctly stored or disposed of correctly. However, we also found staff received training and competency assessments took place to ensure staff had the skills and ability to administer medicines safely.