CQC report explained · a nursing home
What the CQC found at Barton Brook 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 2023
Barton Brook Care Home was rated Inadequate and placed in special measures after inspectors found serious safety and leadership failures.
This was an unannounced inspection. Inspectors visited on 26 and 27 September and 3 October 2023. They spoke with people, relatives and staff, and reviewed care plans, recruitment files, training records and quality checks.
Inspectors found that risks from falls, skin damage, altercations and the environment were not managed reliably. Staffing levels were not always enough, care records contained conflicting information, and some restrictions were used without the required mental capacity assessments. People were not always treated with dignity.
There were also positive findings. Staff were trained and recruited safely, people received support with meals and healthcare, and inspectors observed kind relationships between staff and people. However, the overall rating fell from Requires Improvement to Inadequate because the problems were widespread and included breaches of regulations.
The home is in special measures. The regulator will monitor it and expects an action plan. It said it would usually re-inspect within six months, and could take steps to prevent the home from operating if there is not enough improvement.
Food and mealtime support
People received help to eat and drink when needed. They were offered choices and visual information about the meals.
“Despite staff being busy, people received the support they needed to eat and drink and were able to eat independently if possible.” from the report
Safe recruitment
The required recruitment checks were completed, including interviews, references and DBS checks.
“Staff were recruited safely, with all the necessary procedures followed including interviews, seeking references and carrying out DBS checks.” from the report
Healthcare support
People were referred to relevant healthcare professionals when needed. Modified diets and supplement drinks were provided where required.
“People received support from other health care professionals where needed such as speech and language therapy (SaLT) and dieticians.” from the report
Risks were not controlled
seriousCare plans and risk assessments were not always accurate or followed. Inspectors found missed falls precautions, incomplete repositioning records and an unsafe mattress.
“Risks within the service were not well managed.” from the report
Safeguarding responses
seriousStaff did not always respond properly to physical and verbal altercations. Required observations and records were sometimes missing.
“People were not always safeguarded from abuse.” from the report
Not enough staff
seriousPeople and staff reported shortages, and inspectors saw delays and people moving unsafely without the support stated in their care plans.
“There weren't always enough staff available to keep people safe and there was high reliance on agency staff to ensure rotas were filled.” from the report
Consent and restrictions
seriousRestrictions such as one-to-one care, covert medicines and sensor equipment were not always supported by mental capacity assessments and best-interest decisions.
“MCA assessments were not always completed to ensure these decisions were in people's best interests.” from the report
Dignity and activities
needs fixingInspectors saw poor personal presentation, exposed clothing and open toilet doors. Activities were limited and some people were left unstimulated.
“There was a lack of activities for people during the inspection and we observed people were predominantly seated in lounge areas, unstimulated throughout the day.” from the report
Weak leadership and records
seriousThere was no registered manager during the inspection, five managers had held the role in the previous year, and quality systems had not corrected known problems.
“There had been a lack of leadership at the home in the past 12 months, with 5 different home managers in post.” from the report
- 01What immediate changes have been made to prevent falls, pressure damage and unsafe movement around the units?
- 02How many permanent and agency staff are currently working on each unit, and how do you ensure people receive the support stated in their care plans?
- 03Have all mental capacity assessments and best-interest decisions been completed for people receiving one-to-one care, covert medicines or sensor alarms?
- 04Who is now leading the home, and what is the plan to appoint and retain a registered manager?
- 05What activities, communication support and complaints arrangements are now available for people and relatives?
The inspection began as a focused review of staffing, safeguarding, falls management and leadership, but was widened to a comprehensive inspection covering all five key questions. This explanation was written from the published report of 8 December 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, July 2022
Rated Requires Improvement; inspectors found kind and effective care, but serious gaps in records and oversight.
This was the first inspection since the home registered with CQC under the new provider. Inspectors visited on 20 and 26 May 2022, spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
People and relatives generally said they felt safe and well cared for. Inspectors found enough staff, safe recruitment, suitable training, good support with food and drink, respectful care and care plans that usually reflected people's needs.
There were important problems with record keeping. Medicine, food and drink, and repositioning records were not always complete or accurate. Inspectors also saw an unsafe moving and handling transfer and found that a controlled drugs incident had not been reported promptly.
The overall rating is Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement. The home breached Regulation 17 on good governance because records were not always accurate, complete and up to date.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff spending time with people and supporting their dignity and independence.
“During the inspection we spent time carrying out observations and saw lots of nice interactions between staff and people living at the home.” from the report
Support with needs and choices
Care needs were assessed and staff worked with health professionals when needed. People were supported to make choices and families were involved in decisions where appropriate.
“People's families were involved in this process to help people make these decisions.” from the report
Infection control
Inspectors were assured about testing, PPE, visiting arrangements, hygiene and the home's ability to prevent or manage infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Incomplete care records
seriousRecords for medicines, food and drink, and repositioning were not always accurate or complete. This meant inspectors could not always tell whether people had received the care they needed.
“Accurate and contemporaneous records were not always maintained regarding medication, food/drink and skin care.” from the report
Medication reporting
seriousSome medicine administration records were completed inaccurately. A controlled drugs discrepancy had not been reported to safeguarding services or the police promptly.
“Prior to our inspection, there had been an incident where there had been a discrepancy with one person's controlled drugs which could not be accounted for.” from the report
Activities were uneven
minorFeedback about activities was mixed. Some people and relatives wanted more activities as restrictions were lifted.
“I am disappointed as it says on the website about activities, but only know about bingo now and then.” from the report
- 01What changes have been made to ensure medicine administration records are completed accurately every time?
- 02How are food, drink and repositioning records now checked for gaps or inaccuracies?
- 03What action was taken after inspectors saw an unsafe drag lift, and how is moving and handling practice monitored now?
- 04What happened after the controlled drugs discrepancy, and how are safeguarding concerns reported promptly?
- 05What activities are now available, and how are residents' interests and feedback used to plan them?
This was a first comprehensive inspection of the newly registered service and covered all five CQC questions, with visits on two days and further checks by telephone and email. This explanation was written from the published report of 20 July 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 Barton Brook Care Home
4 rated inspections over 6 years: the service has slipped, from Requires improvement to Inadequate.
- December 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2022Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021Inspected but not ratedSafe: Inspected but not rated
- April 2021Inspected but not ratedSafe: Inspected but not rated
- January 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2022
Registered with the Care Quality Commission on 8 April 2022.
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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At least 100 live-in carers within about an hour of Salford
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 90 can care for a couple. 10 years' experience on average.
“Primrose is a very kind and compassionate healthcare professional”
“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.