Barclay Services

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• 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

The provider's systems and processes that assess, review and mitigate risks were not sufficiently robust. People's care plans, risk assessments and protocols were not consistently reflective of people's current needs and guidance was not sufficiently detailed, or inconsistent. The concerns demonstrate a breach of Regulation 17 (2)(b)(c)Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Some information kept in relation to the service was not relevant or out of date. Staff described an open culture, and that leaders listened to any concerns they wished to raised. Whilst staff could describe their roles, and the checks that should take place to drive improvements, we were unable find any evidence of the staff raising concerns in respect of the issues identified during the assessment.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were positive about being able to speak up; they were confident to use the provider's safeguarding, whistleblowing procedures and reported the management team were supportive and approachable.

The provider operated an open door policy and the regional manager visited regularly. Staff monthly meetings included opportunities to discuss concerns as a standard agenda item.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us they understood their roles and the checks that should happen within the service to drive service improvement. However, a number of the recording issues identified were in records which staff would look at regularly. We were unable to find evidence that staff had raised these errors to the management prior to the assessment.

A number of concerns were identified in respect of the provider's oversight of the service. The provider had completed a service improvement plan however, this lacked detail in relation to outstanding actions and the timescale for completion. It was not fully reflective of actions required to make improvements. Some actions which had been identified by the provider were missing from the improvement plan. The systems and processes for record keeping were not effective, as a number of care records were found to contain inconsistent or inaccurate information about people. Other information in respect of the service was not relevant or out of date. We were unable to review the provider's complaints file as the registered manager was unable to locate the complaint's file during the inspection. Agency staff profiles were kept at the provider's head office. This meant the staff member in charge at each individual building was unable to verify the identity of agency staff members arriving for a shift. Medicines records were not uniform across the individual buildings. This had not been identified by the provider prior to the assessment. Medicine audits had also failed to identify missing or incorrect information.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.