CQC report explained · a nursing home
What the CQC found at Barrowhill Hall
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2023
Rated Good overall; inspectors found safe care and clear improvements, but the home’s leadership and monitoring still Requires Improvement.
This was an unannounced, focused inspection on 1 December 2022. Inspectors reviewed whether earlier problems had been fixed and looked at concerns about falls. They spoke with people, relatives, staff and visiting professionals, and checked care, medicine, recruitment and management records.
The home was rated Good for Safe. Inspectors found better risk monitoring, safer medicine management, suitable staffing and effective infection control. They found no evidence that people were at risk of harm from the concerns about falls.
The home was rated Requires Improvement for Well-led. Management systems had improved, but many were new and had not yet shown that they would work reliably over time. There were still gaps in some care records and monitoring.
The overall rating improved from Requires Improvement at the previous inspection, published in September 2022, to Good. The provider was no longer in breach of the regulations identified at that inspection, but CQC said it would continue to monitor the home.
Improved risk management
The home had improved how it assessed and monitored risks such as falls, skin problems and fluid intake. It worked with health and social care professionals to reduce risks.
“Risks to people were safely assessed. The provider monitoring people at risk of falls and skin integrity concerns.” from the report
Safer medicines
Medicine management had improved significantly. The home had safeguards for medicines given covertly and people received pain relief in line with their needs and preferences.
“There had been significant improvements with the safe managing of medicines.” from the report
Enough suitable staff
Recruitment checks had been completed and inspectors saw enough staff, including support for people needing one-to-one care. Staff received training and supervision.
“The service had enough staff, including for one-to-one support. We saw staff supporting people in a timely manner and engaging in activities with people.” from the report
Open and inclusive culture
Relatives, staff and visiting professionals described improvements under the new manager. They said people and families were listened to and could raise concerns.
“Relatives told us they felt included in the care provided and able to confidently raise concerns.” from the report
New systems not yet proven
needs fixingMany governance systems were newly introduced. CQC said they needed time to show that they could monitor risks and quality effectively.
“Although, many systems were newly introduced, and needed time to ensure these are effective when ensuring good governance.” from the report
Gaps in care monitoring
needs fixingSome records did not clearly show how often a person should be weighed, and bowel monitoring was not fully reflected in the care plan. The manager corrected these issues during the inspection.
“However, how often people should be weighed was not always clear.” from the report
Medicine records needed checking
needs fixingInspectors found a couple of differences between medicine stock and the records. These were corrected during the inspection, but the new auditing system still needs to be tested over time.
“Although, we found a couple of discrepancies between stock and medicine recordings.” from the report
- 01How are you now checking that care plans accurately record bowel monitoring, weight checks and other individual care needs?
- 02How do you audit medicines, and what happened after the discrepancies between medicine stock and records were found?
- 03What evidence do you have that the newly introduced governance and auditing systems are working consistently?
- 04Has the new manager completed registration with the CQC, and who is responsible for the home until that is completed?
- 05What steps are being taken to reduce falls and review medicines for people at risk of falling?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 7 January 2023 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 2022
Rated Requires Improvement; inspectors found risks, medicines records and governance were not consistently managed, and issued a warning notice.
This was an unannounced focused inspection. Inspectors visited on 21 and 22 June 2022, spoke with people, relatives and staff, observed care, and checked care records, medicines records, incident reports and management systems.
The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. Inspectors found that some risks were not properly assessed or recorded, medicines records were incomplete, and some incidents were not reported or investigated. The quality checks used by managers had not found these problems.
There were also positive findings. Inspectors found enough staff, safe recruitment checks, suitable infection control measures, and support for people's choices and best-interest decisions. Relatives said staff were kind and that they were told when incidents happened.
The overall rating was unchanged from the previous inspection on 5 November 2021. This was the fifth consecutive inspection where the home had not achieved a Good rating. The other key question ratings were carried forward from the previous inspection because this inspection only focused on Safe and Well-led.
Enough staff
Inspectors found enough staff to meet people's needs, with no delays in the care they observed. Recruitment checks were also carried out.
“We saw people had the care they needed without any delays.” from the report
Infection control
Inspectors were assured that infection prevention measures, including protective equipment, testing, hygiene and visiting arrangements, were in place.
“We were assured that the provider was using PPE effectively and safely.” from the report
Choice and legal safeguards
People's capacity was assessed where needed, best-interest decisions were recorded, and appropriate applications were made when restrictions on liberty were required.
“People had their capacity assessed and where required decisions were taken in their best interests and recorded.” from the report
Learning from reported incidents
When incidents were reported, the registered manager reviewed them and took action intended to reduce the chance of them happening again.
“There was a monitoring system in place which reviewed incidents and accidents to look for trends.” from the report
Risk plans were incomplete
seriousSome risks were identified but there was no clear guidance for staff on how to reduce them. Care plans were also not always updated when people's needs changed.
“This meant people were left at risk of harm.” from the report
Medicines records were not reliable
seriousSome medicines administration records had missing signatures, so inspectors could not be sure medicines had been given as prescribed. Records about changing injection sites were also not completed properly.
“We found MAR charts with signatures which had been missed and we could not be assured people had received their medicines.” from the report
Some incidents were not reported
seriousStaff did not always report incidents for investigation. This included an incident involving possible restraint, which left a person at risk.
“One incident where a person was exposed to potential restraint had not been reported and investigated.” from the report
Management checks missed problems
seriousThe home's audits and monitoring systems did not identify important safety and care-record issues or make sure action was taken.
“The quality monitoring systems in place were not identifying concerns and driving improvement in the service.” from the report
Communication with relatives
needs fixingRelatives said emails were not always answered and that it could be difficult to speak with the registered manager. Some also reported long waits for dentist and optician visits.
“They are not very good at communicating. Emails are not answered, and we have to do all the chasing.” from the report
- 01What action has been taken to make sure every person's risks, including risks linked to emotional distress, diabetes and epilepsy, have a clear management plan?
- 02How do you check that medicines administration records and body-map records are completed correctly every time?
- 03How are incidents, including possible restraint, reported, investigated and used to prevent harm?
- 04What has changed in the auditing system since this inspection, and how can families see that improvements are being checked?
- 05Who should relatives contact if emails are not answered or they need to speak with the registered manager?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 13 September 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 Barrowhill Hall
8 rated inspections over 7 years: the service has held its Good rating throughout.
- January 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2022Inspected but not ratedSafe: Inspected but not rated
- November 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- May 2019Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- December 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2012
Registered with the Care Quality Commission on 1 November 2012.
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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