CQC report explained · a nursing home
What the CQC found at Barnham Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks were assessed and managed, including detailed emergency evacuation plans. Inspectors found enough staff, safe medicines systems, robust recruitment and a very clean home.
- Effective?
- Good
- Staff were trained to meet people's specific needs, and people received appropriate food, healthcare and support from other professionals. Mental capacity and best-interest processes were followed.
- Caring?
- Good
- Staff knew people well and treated them with kindness, dignity and respect. People were involved in decisions, and their privacy, independence and personal identity were supported.
- Responsive?
- Good
- Care was personalised around people's preferences and routines. People had access to activities, family visits, outings, communication support and compassionate end of life care.
- Well-led?
- Good
- The manager and provider had improved quality checks and acted on feedback and audits. People, relatives, staff and professionals spoke positively about the leadership and communication.
What inspectors found, September 2019
Rated Good; inspectors found safe, kind and personalised care, with significant improvements since the previous inspection.
The inspection was unannounced and took place on 30 August 2019. One inspector and an Expert by Experience spoke with people, relatives, staff and health professionals. They also observed care, checked five people's care records and reviewed records such as accidents, complaints, audits and recruitment files.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, good cleanliness, suitable training and prompt access to health professionals. People were treated with kindness, offered choices and supported to keep their independence and relationships.
The previous rating was Requires Improvement, with three regulatory breaches. Inspectors found that the provider had acted on its improvement plan. The home was no longer in breach of regulations at this inspection.
Improved safety systems
The home had improved its emergency planning and its approach to accidents and incidents. The manager analysed incidents and used the findings to reduce risks, including falls.
“The registered manager now analysed all incident reports to identify trends and support people's safety.” from the report
Kind and respectful care
Staff knew people well, respected their choices and protected their dignity and privacy. People were supported to make decisions and remain as independent as possible.
“People received kind and compassionate care from staff who knew them well.” from the report
Personalised support
Care plans included people's life histories, preferences and preferred routines. People could choose how they spent their time, when they bathed or showered and when they went to bed.
“People received personalised care that was responsive to their individual needs.” from the report
Good health and nutritional support
People's health needs and specialist diets were supported. Staff worked with health professionals and arranged appointments and treatment when needed.
“People who required specialist diets were supported in line with their assessed needs.” from the report
Activities and relationships
People had varied activities linked to their interests and were supported to maintain important relationships. Relatives were welcomed, and staff helped people attend family and religious events.
“People had access to a variety of activities that were tailored to their interests.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you continue to review and update my relative's personal emergency evacuation plan?
- 02How do you monitor accidents, incidents and falls, and how will you share any changes to my relative's support?
- 03Which staff are trained and assessed to administer my relative's medicines, including any medicines prescribed as needed?
- 04How will you support my relative's specific communication needs, interests, routines and relationships?
- 05How do you involve families in reviewing care plans and responding to concerns?
This was a planned, unannounced inspection covering all five CQC questions; the previous Requires Improvement rating and three breaches had been followed up and were no longer in place. This explanation was written from the published report of 12 September 2019 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, September 2018
Barnham Manor was rated Requires Improvement; inspectors found kind staff and effective care, but serious evacuation risks and inconsistent personalised care.
This was an unannounced comprehensive inspection on 17 May 2018. Inspectors observed care, spoke with people, relatives and staff, and checked care records, medicines, training, incidents and management records.
The home was rated Good for Effective. People generally received suitable food, medicines and healthcare. Staff were trained, there were enough staff, and the home was clean and well maintained.
The home was rated Requires Improvement for Safe, Caring, Responsive and Well-led. People did not have individual evacuation plans, equipment for evacuation was not easy to reach, and staff could not always explain how people would be moved safely in an emergency. Falls were not always followed up properly.
Inspectors also found that people were sometimes expected to follow set routines for getting up, going to bed and bathing. The home had improved the security of care records since the previous inspection, but the overall rating fell from Good to Requires Improvement.
Enough suitable staff
Recruitment checks were completed, staffing levels were maintained and people generally said call bells were answered promptly.
“Staff recruitment procedures ensured only those staff suitable to work in a care setting were employed.” from the report
Kind and respectful care
Inspectors saw staff speaking warmly to people. People said staff were compassionate and respected their privacy and dignity.
“We observed people being treated with kindness and compassion.” from the report
Food and healthcare
People generally enjoyed the food and could ask for alternatives. Staff recognised changes in people's health and sought professional help when needed.
“They're always asking me if I'm okay. If I wasn't feeling very well they'd know quickly and would call the doctor out” from the report
Improved record security
The previous problem with care records being accessible to visitors had been addressed by this inspection.
“At this inspection on 17 May 2018 we found improvements had been made and the provider was no longer in breach of Regulation 17.” from the report
Emergency evacuation planning
seriousPeople did not have personal evacuation plans. Evacuation equipment was stored where it would be difficult to obtain quickly, and some staff could not explain how they would move people safely.
“People did not have personal evacuation plans (PEEPs) in place.” from the report
Falls were not fully reviewed
needs fixingThe home recorded falls and accidents, but records did not consistently show what caused them or what had been done to reduce the chance of them happening again.
“There was no record or analysis that identified how incidents had occurred, or what actions had been taken to make improvements when things had gone wrong.” from the report
CCTV consent
minorThe home had installed CCTV in communal areas but had not obtained written consent from people before using it.
“The provider had not sought or obtained written consent from people for this monitoring” from the report
- 01What personal evacuation plan is now in place for my relative, and where is the evacuation equipment kept?
- 02How are falls investigated now, and how do you check that care plans are changed afterwards?
- 03Can my relative choose when to get up, go to bed and have a bath?
- 04How do you now involve residents and relatives in decisions and collect their feedback?
- 05What consent process is used for CCTV monitoring in communal areas?
This was an unannounced comprehensive inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 20 September 2018 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 Barnham Manor
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- September 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- January 2013
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 7 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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Most charge £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
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