CQC report explained · a nursing home
What the CQC found at Barleycroft Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2022
Rated Good overall, but inspectors found weaknesses in leadership, records and business continuity.
This was an unannounced follow-up inspection on 6 October 2022. Inspectors reviewed care plans, risk assessments, medicine records, staff files, rotas, complaints and management records. They spoke with people, relatives, staff and health professionals.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found improvements in medicines, care planning, staffing, safeguarding and working with health professionals. People were generally treated with dignity and supported to make choices.
Well-led was rated Requires Improvement. Some staff had not had recent formal supervision. Information was split between old and new care planning systems, and there was no backup plan when the Wi-Fi failed. The Wi-Fi problem had also delayed some medicines, although the provider acted and later introduced a contingency plan.
The previous rating was Requires Improvement and the home had been in Special Measures. Inspectors found the earlier legal breaches had been addressed, so the home was no longer in Special Measures.
Improved medicines management
Medicines were being managed consistently, with daily checks, staff competency assessments and accurate records.
“At this inspection, we found medicines were managed consistently and safely in line with national guidance.” from the report
Kind and respectful care
Inspectors saw friendly interactions and found that staff generally respected people's privacy, dignity, choices and independence.
“During our visit we saw staff interacting with people in a kind and friendly manner.” from the report
Personalised support
Care plans had improved and included information about people's needs, preferences and communication. People and relatives were involved in decisions about care.
“At this inspection we found there had been improvements made to the care plans.” from the report
Activities and relationships
People could take part in chosen activities and were supported to keep in touch with relatives.
“People took part in activities which they had chosen to help ensure they were not socially isolated.” from the report
Working with health professionals
The home worked with GPs and other professionals to respond to changing health needs.
“The service had an effective working relationship with a number of health care professionals to ensure that people received co-ordinated care and support.” from the report
Staff supervision
needs fixingNot all staff had received a recent formal supervision meeting. Inspectors made a recommendation for regular formal supervision.
“However, we noted not all staff had received a formal supervision meeting recently.” from the report
Care records in two systems
needs fixingSome care information was still in the old system, making it difficult at times to find information about people's medical conditions.
“It was at times difficult to find if people had a care plan regarding their medical conditions, because of the two systems.” from the report
Wi-Fi and medicine delays
seriousThe Wi-Fi failed intermittently and caused delays in some people receiving medicines on time. The provider acted during and after the inspection, including putting a contingency plan in place.
“For example, there was a delay in people receiving their medicines on time as the provider used electronic medicine administration records.” from the report
Mixed feedback about staff interactions
needs fixingAlthough many people described staff positively, inspectors received mixed feedback. One person said staff did not talk to them much, and one relative said that some staff were not kind.
“People were not always well treated and supported.” from the report
Privacy incident
minorInspectors found one instance where staff entered a person's bedroom without first asking permission. This was raised with the management team.
“However, we found one instance where staff went into a person's bedroom without seeking their permission.” from the report
- 01How are you making sure every member of staff receives regular formal supervision and an annual appraisal?
- 02Have all care records now been moved from the old system to the new system, and how do staff find medical information quickly?
- 03What is the current backup plan if the Wi-Fi or electronic medicine records fail?
- 04How do you check that medicines are given on time when there is an electronic system problem?
- 05What action has been taken after feedback that some staff did not talk enough or were not always kind?
This was an unannounced follow-up inspection covering all five key questions, with infection prevention and control also reviewed, after earlier concerns and Special Measures. This explanation was written from the published report of 10 November 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
Rated Requires Improvement and remains in special measures; inspectors found unsafe medicine records and weak oversight, although some areas had improved.
Inspectors made unannounced visits on 9 and 15 December 2021. They reviewed care plans, risk assessments, medicine records, staff files and management records. They also spoke with people, relatives and staff, and observed care.
The home was rated Requires Improvement overall. Safe, effective, caring and responsive were also Requires Improvement. Well-led was Inadequate. Inspectors found that medicine stock records did not always match the medicines held, some records were not personalised, and checks did not reliably identify safety problems.
There were some improvements since the previous inspection. Risk assessments, staff training, accident reviews, safeguarding information and infection control had improved. However, the home had not made enough progress and remained in breach of regulations 9, 12 and 17.
The home had been in special measures since 2 June 2021 and remains there. CQC said it would keep the home under review and normally re-inspect within six months to check for significant improvements.
Enough staff
Inspectors found staffing levels reflected people's needs, and the home did not use agency staff. Recruitment checks were also in place.
“The registered manager ensured there were sufficient numbers of staff available to meet the needs of people.” from the report
Improved staff training
Staff had received training in areas including nutrition, end of life care, catheterisation, epilepsy and diabetes. Staff induction and competence checks were also in place.
“At this inspection we found staff had received the training needed to support people and meet their needs.” from the report
Kind interactions
Inspectors saw staff being patient and respectful. People had privacy in single bedrooms and were encouraged to remain independent.
“We saw some warm, kind and patient interactions between staff and people who use the service.” from the report
Access to healthcare
The management team worked with health professionals, and records showed referrals were made without delay when people became unwell.
“People were supported to maintain good health and to access health care services and professionals when they needed them.” from the report
Medicine discrepancies
seriousThe recorded medicine stock did not match the actual stock for two people. The home could not establish when the errors happened or confirm whether the medicines had been given correctly.
“This meant not all medicines could be accounted for.” from the report
Weak quality checks
seriousAudits did not identify medicine discrepancies, faulty window restrictors, a propped-open fire door or other safety concerns. Inspectors found the home was still in breach of the good governance regulation.
“The above evidence shows that the provider did not have effective systems to assess, monitor and improve the quality and safety of the service” from the report
Incomplete personal information
seriousCare records did not always record choices about personal care, food and drink. Information about culture, sexuality and some end of life wishes was limited or not individualised.
“We did not see records of people's preferences regarding personal care, such as whether they would prefer a strip wash, shower or a bath.” from the report
Inconsistent thickener records
needs fixingRecords did not consistently show whether thickener had been added to all drinks or how much had been used. This meant people were at risk of unsafe support.
“There were various days for the past two weeks before our inspection where this had not been completed by the staff” from the report
Mixed activities and food feedback
minorPeople gave mixed views about activities and food. One person said activities were rare, while another said they enjoyed them.
“We received mixed feedback about the activities within the service.” from the report
- 01How do you now check medicine stock against electronic records, and what happens if there is a discrepancy?
- 02How do you record each person's choices about bathing, personal care, food and drink?
- 03How do you make sure thickener is added in the correct amount and recorded for every relevant drink?
- 04What checks now identify fire safety problems, faulty equipment and other environmental risks?
- 05What progress has been made since the inspection, and when will the home leave special measures?
This was an unannounced follow-up inspection covering all five key questions, with infection prevention and control also reviewed; it checked progress after the previous inspection but could not assess new-admission assessments because there had been no new admissions. This explanation was written from the published report of 25 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Barleycroft Care Home
3 rated inspections over a year: the service has improved, from Inadequate to Good.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2021InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2019
Registered with the Care Quality Commission on 17 December 2019.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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