Barn Park Residential Home

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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

There was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Systems and processes to assess and monitor the quality and safety of the service were not sufficient to ensure compliance with regulations. This meant there was not effective oversight of people’s safety and well-being.

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.

Due to unforeseen circumstances, a planned handover linked to the management of the home did not happen. It was due to take place over several months to enable the new manager to learn new skills and processes. Around the same time, the provider, who remained in regular contact with the new manager, had to limit their visits and their contact with staff and people living at the home. This meant the new manager had not received the level of support and guidance which had been planned. Since the assessment, the local authority’s quality and improvement team have visited the manager to offer guidance and support. People were not always informed in a timely way about changes at the service. A letter had not been sent to people living and visiting the home regarding the change of manager and changes to overseeing the safety of the service. The manager said they had met with families when they visited or spoken to them on the phone. Several relatives said they were not aware there was a new manager, but others described the manager as helpful and approachable. For example, “I think she is doing a good job, and she will certainly answer any queries I have” and “I think (Manager) is thorough and doesn’t miss a trick. She knows what she is doing.” There had been poor working relationships amongst some team members, creating a divided team on some shifts. This had the potential to impact on people’s care and eroded the confidence and morale of some staff. The impact was discussed with the provider and the manager; disciplinary measures were starting. Since the assessment the manager told us staff changes had improved the atmosphere and teamwork to benefit people living at the home.

People had not been given the opportunity to express their views about their service through a survey or a meeting. There were no formal processes for relatives to comment on the care and the running of the home, which relatives said should be improved. For example, one said, “It is often difficult to get through on the phone. They used to do a newsletter but that has stopped. I don’t know who is doing the activities now as I think the person left. I haven’t been asked for my opinion on the service and I don’t feel I have any involvement in the running of the home.” However, relatives said they would recommend the home because of the relaxed atmosphere, and the positive attitude of the staff. Complaints information was displayed by the front door, but it was not easily accessible, and the information was out of date. People said they had not raised a complaint but were confident the manager would address concerns.

A staff meeting was planned, and staff were positive they could approach the manager or the provider with concerns. The manager said they could contact the provider for support.

Based on conversations with staff and staff records, staff supervision was not happening on a regular basis for all the staff. The manager was planning to address this issue. Supervision should provide a time for staff to discuss areas of concern as well as areas for growth in a regular confidential meeting.

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.

The new manager was working hard to implement and improve ways of working, including the quality of recording. However, we saw they were constantly interrupted by telephone calls and staff; there was no administration support for the manager. Since the assessment, a decision has been made for an experienced member of staff to support the manager implement improvements and address recording issues. The provider did not keep a formal record of the work undertaken to improve the appearance and maintenance of the home. This meant there were no recorded timescales or prioritisation.

We found systems and processes to assess and monitor the quality and safety of the service were not sufficient to ensure compliance with regulations. The governance systems failed to identify people’s care records did not provide adequate guidance to staff, such as environmental and safeguarding risks. Care records contained gaps which meant there was poor oversight of people’s nutrition or personal care. Medicine practice did not follow national guidelines for safe practice. There were inadequate systems to regularly monitor staff skills and training. The manager said they regularly covered different shifts which enabled them to monitor staff as they worked alongside them. However, these were not routinely recorded to provide an effective audit. There was lack of oversight of the service to review the quality of work of the manager and staff, and to ensure people were safe. The service’s records were paper based, this impeded off site audits to check on the quality of the care and the running of the home. Care records were not regularly reviewed and audited so there was no record of how identified risks to people’s health and safety were being monitored. Records completed by care staff were not regularly reviewed either with the person receiving the care, or where appropriate, their family. This meant known risks were not routinely addressed and people’s social and emotional needs were not always met. Robust systems and processes were not in place to ensure people were always supported to make decisions about their care and treatment within the principles of the Mental Capacity Act 2005 (MCA). Mental capacity assessments and best interests decisions were not always in place where people had restrictions placed on them. People’s capacity to understand decisions had not always been assessed. Some people were being restricted unlawfully as deprivation of liberties applications had not been made.

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.