CQC report explained · a nursing home
What the CQC found at Barnfield Manor 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, December 2022
Rated Requires Improvement; inspectors found better safeguarding and staffing arrangements, but medicines management and oversight were still not reliable.
This was an unannounced focused inspection on 26 October 2022. Inspectors checked whether earlier improvements had been made, focusing on Safe and Well-led. They spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
People were protected from abuse, and safeguarding concerns were reported and investigated correctly. Risks linked to mobility, skin condition and weight were recorded and understood by staff. Infection prevention arrangements were also found to be satisfactory.
However, medicines were not always managed safely. Records for a pain-relief patch were incomplete, some medicine training was overdue, a medicines fridge temperature problem had not been identified, and the ordering system caused unnecessary waste. The home had improvement plans, but inspectors said these changes needed to be put into practice and maintained.
The overall rating remained Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used.
Safeguarding
Staff knew how to report abuse concerns, and safeguarding incidents had been properly recorded, investigated and referred when needed.
“Safeguarding incidents had been correctly reported, recorded and investigated.” from the report
Risk management
Risks affecting people's mobility, skin condition and weight were recorded and understood by staff. Managers reviewed these risks and took action.
“Risks which affected people's daily lives, in relation to their mobility, skin integrity and weight were documented and known by staff.” from the report
Infection control
Inspectors were assured about infection prevention, use of protective equipment, visiting arrangements and managing possible outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Person-centred information
Care plans had been reviewed and included information about people's preferences and choices, including how to support someone who was distressed.
“People's care plans had been reviewed and updated following our previous inspection.” from the report
Activities and engagement
The home had recruited an activities coordinator who provided both group and one-to-one activities.
“The activities coordinator provided activities to people in a group and on a one to one basis.” from the report
Incomplete medicine records
seriousRecords did not always show where a pain-relief patch had been applied or confirm that it was still in place. Inspectors said this created a risk that it might not be used as prescribed.
“We also found checks to ensure the patch was in place were not always recorded.” from the report
Medicine systems
seriousThe ordering system did not identify stock levels effectively, leading to prescribed medicines being disposed of. Some medicine administration training and competency checks were also overdue.
“The medicine ordering system was not effective in identifying current stock levels as medicines which were still prescribed, were being disposed of creating unnecessary and costly waste.” from the report
Management oversight
needs fixingMedicine audits had not found some of the problems identified by inspectors. The home had an action plan, but needed to show that improvements were embedded and lasting.
“Medicine audits were regularly completed, however they had not identified or actioned some of the issues we found during our inspection.” from the report
Staffing views
needs fixingStaff and relatives gave mixed views about staffing levels. The provider said managers and directors supported care staff at busy times, and inspectors observed this during the visit.
“We received mixed opinions from staff and relatives about staffing levels.” from the report
- 01How have you fixed the records and checks for pain-relief patches?
- 02How do you now check medicines fridge temperatures, and what happens if a temperature is out of range?
- 03Which staff had overdue medicine training, and has everyone now completed the required training and competency checks?
- 04What changes have you made to medicine ordering so prescribed medicines are not unnecessarily disposed of?
- 05How do you check that staffing levels are enough at busy times, and how quickly can managers provide support?
This was an unannounced focused inspection of Safe and Well-led, with infection control also considered; the Effective, Caring and Responsive ratings carried over from the previous inspection. This explanation was written from the published report of 14 December 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; inspectors found risks from staffing, safeguarding, medicines and weak monitoring, and issued a warning notice.
This was an unannounced inspection on 29 September 2021. Two inspectors spoke with people, relatives and staff. They observed care, reviewed care and medicines records, checked recruitment files and examined management information.
The home was not always safe. There were not enough staff on some shifts, and some personal, emotional and medicines needs were not met promptly. Safeguarding incidents had not always been reported or acted on. Cleaning records for high-touch areas were incomplete, and medicines and risk assessments were not consistently managed.
The home was not always well-led. Monitoring systems had failed to identify important problems, and some care plans did not reflect people's current needs or choices. Staff were described as kind, and complaints, meetings and feedback were managed in some positive ways.
The overall rating was Requires Improvement. Safe and Well-led were also rated Requires Improvement. These ratings had fallen from Good at the previous inspection, published in May 2018.
Safe recruitment
The home completed pre-employment checks, including references and DBS checks.
“Staff were recruited safely. The provider completed pre-employment checks such as references and Disclosure and Barring Service (DBS) checks.” from the report
Environmental safety
Inspectors found regular equipment and fire safety checks, and considered environmental risks well managed.
“Environmental risks were well managed, regular checks had been carried out which included equipment checks and fire safety.” from the report
Complaints handling
Complaints had been investigated and resolved promptly.
“Complaints about the service were well managed. We reviewed the complaints the service had received, we found these had been investigated and promptly resolved.” from the report
Feedback and communication
People and relatives could suggest improvements through meetings and questionnaires. Staff meetings took place regularly and staff said communication was good.
“People and their relatives had regular opportunities to suggest improvements to the service through questionnaires and meetings with the manager.” from the report
Staffing levels
seriousThere were not enough staff on some shifts to meet people's needs. The report records that nine day shifts had only two or three care assistants, although the manager said four were needed.
“The provider had failed to ensure enough staff were deployed to meet people's needs. This was a breach of regulation 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Safeguarding and neglect
seriousThree incidents had not been reported to the provider or safeguarding authority. Inspectors also found that people could wait for personal or emotional support because staff were unavailable.
“People had not been protected from the risk of abuse. This was a breach of Regulation 13 (Safeguarding service users from abuse and improper treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Medicines and risk assessments
seriousMedicines ordering was not effective, and the home did not always monitor weights or update risk assessments when people's needs changed. Inspectors did not find evidence that people had missed medicines because of supply problems.
“People were at risk of unsafe care and treatment. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Cleaning records
needs fixingRecords showing that high-touch areas had been cleaned were missing for most of September. The provider said daily checks would be introduced.
“We found that cleaning records for high touch areas had not been completed for the majority of September.” from the report
Person-centred care
seriousSome people's lifestyle choices were not included in care plans or followed. One person's required social interactions were recorded only twice during September.
“The provider had failed to meet people's person-centred care needs. This was a breach of regulation 9 (Person centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Weak oversight
seriousManagement checks did not identify or act on several safety problems, including safeguarding incidents, cleaning records, medicines and incidents affecting staff.
“Systems were not robust enough to demonstrate safety was effectively managed. This placed people at risk of harm. This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
- 01What staffing levels are now provided on each shift, and how do they reflect the home's layout and people's needs?
- 02How do you make sure all safeguarding incidents are reported, investigated and used to prevent a repeat?
- 03How do you check that medicines are ordered in time and that nobody runs out?
- 04How are high-touch cleaning checks recorded and reviewed each day?
- 05How have care plans been updated to reflect people's choices, risks and required social contact?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key questions were not separately rated in this report. This explanation was written from the published report of 19 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 Barnfield Manor Care Home
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- December 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- May 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 2010.
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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