Barton Place Nursing Home

People’s experience of using this service and what we found

Barton Place had been through a challenging period related to the recruitment and retention of staff and the Covid 19 pandemic. During this period, they had been proactive in adopting measures to ensure people continued to be supported safely. The recruitment and staffing difficulties were now resolving, and the service was opening up again to visitors after the lockdowns. Relatives’ meetings were being reinstated and action being taken to increase their involvement and engagement with the service.

There were systems in place to monitor the quality and safety of the service, but it had been challenging to complete the full range of audits given the operational difficulties facing the service. Despite this, key audits had been completed and the registered manager had a detailed knowledge of where improvements were needed. The provider and registered manager were now in the process of improving and streamlining governance processes to make them more effective.

People felt safe living at Barton Place, and we observed the interaction with staff supporting them was relaxed. Staff were recruited safely, and safeguarding processes were in place to help protect people from abuse. Risks associated with people's care had been assessed and guidance was in place for staff to follow. Care plans were detailed, and person centred, with needs and risks reviewed with staff on a daily basis. This meant staff were kept informed about the support people needed.

Staff received the training they needed to keep themselves and people safe and meet their needs. This included supporting people who were expressing distress and/or agitation. This meant their healthcare and nutritional needs were met. External professionals were complimentary about how the service worked in partnership with them.

People received their medicines safely, and in the way prescribed for them. The provider had good systems to manage safeguarding concerns, accidents and environmental safety.

Barton Place provided a person-centred service. The care provided was sensitive to people's diverse needs. Staff effectively supported people’s communication which meant they could express their views and make choices about how they wished to be supported.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 08 May 2019)

Why we inspected

We received concerns in relation to staffing; the management of risks; poor moving and handling; abuse; infection prevention and the management of the service. As a result, we undertook a focused inspection to review the key questions of Safe and Well-Led only. We found no evidence during this inspection that people were at risk of harm from these concerns.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

People’s experience of using this service:

• A new manager had started working in the home a few days before this inspection took place. People, relatives and staff spoke positively about the new manager and told us they had already seen improvements, such as better staffing levels and management structure. . A relative told us “I've met the new manager and things seem to be changing for the better”. A member of staff told us, “We feel absolutely supported by the new manager, [name] Honestly, I feel lucky she accepted this post, she supports us well”.

• Quality monitoring and improvement systems had not been fully effective. In the interim period while the service was without a registered manager some areas such as staff training and supervision had not been carried out effectively. The provider and new manager had plans to implement new quality monitoring systems in the near future.

• People told us they felt safe. There were sufficient staff employed to meet people’s needs safely. New staff had recently been employed and this meant the use of agency staff had reduced. Some gaps in staff training needs had been identified by the new manager and actions had been taken promptly to provide a good level of training to all staff. New systems had been established to ensure all staff receive the supervision and support they need.

• People’s needs had been assessed before they moved in and care plans were in place to ensure staff had information on all aspects of people’s medical, social and personal care needs. Risks to people’s health and safety had been assessed and systems, care and equipment were in place to minimise the risks and ensure people were supported safely.

• People and relatives told us the staff were caring and treated people with respect. Staff were observed sitting and talking to people, and giving people the time they needed. All interactions between staff and people were gentle, kind and respectful.

Rating at last inspection: The service was inspected on 16 and 20 October 2017 when the service was rated as Good.

Why we inspected: Before the inspection we received information and notifications which indicated there may be some areas of concern at the home. These included allegations of missing personal belongings, poor skin care and high staff turnover. Issues relating to poor skin care were resolved quickly. The service had been without a registered manager for approximately three months so we decided to bring the inspection forward by a few months to provide re-assurance the home was being properly managed and providing people with safe care. During our inspection we found there was a new manager in post who had quickly identified areas where actions and improvements were needed and was in the process of taking action to address these. They were working closely with relevant agencies where necessary.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Barton Place Nursing and Residential Home is registered to provide accommodation for up to 42 people who require nursing and personal care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of this inspection there were a total of 34 people living there.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe. A relative told us they would not hesitate to report any concerns to the registered manager or deputy manager and said "I feel confident with them". The service protected people from the risk of abuse through appropriate policies, procedures and staff training. All staff had received training and updates on how to recognise and report any suspicions of abuse. Checks and references had been taken up before staff began working at the home. The provider told us new staff were not confirmed in post until they had checked the records to ensure all required evidence was in place and they were satisfied the applicants were entirely suitable.

People and relatives told us there were enough staff employed to meet people's needs safely. Staff rotas showed there were sufficient staff on duty at all times of the day and night. In the last year the number of permanently employed staff had increased, and the number of agency staff had reduced. This meant people were receiving a more consistent service from staff who knew them well and understood their needs.

Risks to people's health and safety had been assessed and regularly reviewed. The home used an electronic care planning system that showed risk assessments had been carried out on all potential areas of risk, for example nutrition, hydration, moving and handling, choking, falls and continence. Staff had a very good understanding of each person's needs and provided care that took account of individual needs and wishes. Staff were able to describe each person's interests, personality, likes and dislikes. They understood people's daily routines and we saw the care plans reflected the care people received throughout the day, which was in line with their care plan.

Medicines were stored and administered safely. People living in the home and their relatives told us they were confident their medicines were looked after and administered safely. Staff were well trained and followed safe procedures when administering medicines. Records of prescribed tablets and liquid medicines were signed for each time they were administered. Medicines were regularly audited to ensure safe procedures were followed.

The home was well maintained, clean and hygienic. Comments from people living in the home and relatives included, "Fantastic. His room is spotless. They didn't know we were coming in today", "Cleanliness seems to be very good. Its clean here, they seem proactive with hygiene.” Equipment such as gas, electrical equipment, hoists, life and fire safety equipment were regularly checked and serviced.

The provider and registered manager had taken actions to ensure people’s legal rights were protected. Where people lacked the capacity to make important decisions about their lives mental

capacity assessments had been completed. The provider told us in their Provider Information return (PIR) "Staff receive training in managing violence, aggression and dignified breakaway. Staff have training and an understanding of the Mental Capacity Act 2005, deprivation and liberty is included in their training and the use of restraint."

People received care from staff who understood their needs and communicated well with them. Staff had the skills, experience and knowledge to meet people’s needs effectively. Training records showed that staff had received a range of training, regular updates, and qualifications to provide them with the knowledge and skills to meet people’s needs. Staff were supervised regularly and well supported.

People's nutritional and hydration needs were met, and care was taken to ensure all special dietary needs were catered for. People and relatives told us they were happy with the quality and range of foods offered. Comments included, "I had a lovely dinner, breakfast. Lots of drinks", "I've got allergies to some things such as strawberries and different things. Home know that" and "Very good. [Person's name] can't feed himself, they're doing it fine. The thing is not to hurry him. He's eating well".

People continued to receive care from staff who were kind, respectful and understanding. Staff were attentive, and chatted to each person frequently throughout the day. Comments from people living in the home and their relatives included, "They are always talking to him", and "Yes they come here and sit and talk to her when they have tea breaks.” Staff respected each person as an individual and understood their diverse backgrounds and needs. Staff treated people as unique individuals with their own personality and interests. People could be confident they would receive compassionate care at the end of their lives that had been planned and agreed with them.

Each person's social needs had been assessed and agreed with them. Staff understood the things people enjoyed doing, their past lives, employment and achievements. Two activities organisers were employed on a full time basis providing people with a wide range of group or individual activities throughout the week. There were also visits to the home from a range of professionals such as musical entertainers, music therapists, and dance therapists.

People and their families could be confident any complaints would be listened to, taken seriously and actions taken to prevent similar problems happening again. Complaints procedures were displayed prominently around the home. People’s views and comments on the home were sought, listened to and addressed.

The home was well managed. The provider has systems in place to monitor the quality of the service and make continuous improvements. Staff told us they felt well supported by the registered manager and deputy manager. Staff had developed links and close working relationships with external health and social care professionals, including the local mental health team and community nurses. People were encouraged to maintain close links with the local community.

Barton Place Nursing and Residential Home is registered to provide accommodation for 42 people who require nursing and personal care. At the time of this inspection there were 36 people living there. The home specialises in caring for people with dementia and mental illness. Many of the people we met were unable to hold a conversation due to dementia. We therefore used our observations of care and our discussions with staff, relatives and professionals to help form our judgements.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Since the last inspection we received some concerns about the service. These included concerns about continence care, pressure care management, staff training and support, needs, assessments and referrals and moving and handling, low staff numbers, lack of training, poor moving and handling practice, and poor communication skills of overseas staff. Some of these concerns were investigated by the local authority safeguarding team. They carried out investigations and held strategy meetings to discuss their findings and agree actions. The action plans were agreed with the provider who responded pro-actively in a positive way and the safeguarding process was closed a few days before this inspection took place.

During this inspection we heard that the home had recently experienced a period of high staff turnover. They were in the process of recruiting new staff. There had been some changes in the management of the home over the last year. At the time of this inspection a registered manager had recently returned to work in the home after a break in their employment. Their return to Barton Place was welcomed by relatives and staff we spoke with. The staff team spoke positively about the teamwork and communication in the home since the registered manager’s return. We saw evidence of many improvements that had recently taken place in recent weeks to improve the care of people living in the home. Issues that had been raised through the safeguarding process had been, or were in the process of being addressed. During the inspection we identified some further improvements were needed and the provider and registered manager took prompt actions to address these, or put plans in place to address these as soon as possible.

Where people lacked capacity to make an informed decision the records did not always provide evidence of an assessment of their mental capacity. Where restrictions such as bed rails or pressure mats had been put in place we were unable to check that agreement for these restrictions had been reached through a ‘best interest’ process with people who were lawfully acting on their behalf.

People had not always been protected by robust recruitment procedures. Where potential concerns had been raised through one person’s recruitment checks we could not see evidence that a formal risk assessment had been carried out to determine further actions necessary to ensure the applicants were entirely suitable. The new registered manager and provider gave us assurances that in future safe recruitment procedures would always be followed.

There were sufficient staff employed to meet the needs of people living there. Deployment of staff (staff being in the right place at the right time) had at times been a problem, but was improving. Recent staff changes meant that some new staff were still in the process of learning the job. Senior care posts had recently been established. This had brought about positive changes in the way staff worked. Senior staff carried out regular checks to ensure each person’s care needs were being met in a timely way. For example, records showed people may not have received regular continence support. The provider acted immediately during the inspection to improve the care planning and recording system. This enabled them to monitor staff routines and make sure people received regular continence checks.

The home had recently introduced a new computer based care planning system. Each member of staff had been issued with a hand-held device the size of a mobile phone which they used to record the care tasks they completed throughout the day. The devices gave them access to each person’s care plan and the care the person needed. Information about each person’s needs had been transferred onto the computer system in recent weeks. The care plans provided good information about potential risks such as weight loss, dehydration, pressure sores and choking. Staff were alerted to important actions needed to reduce the risks. There was also evidence of good liaison with other health and social care professionals.

Medicines were generally stored and administered safely. We noted some problems with missing signatures in the medicines administration records (MARS). The registered manager took prompt action to ensure daily checks were carried out on MARS to ensure all records were accurate and provided evidence to show that all prescribed medicines, including creams and lotions are administered safely.

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The home was well maintained and equipment was serviced and checked regularly. There were mild odours in a few areas despite regular ‘deep cleaning’. The providers were aware of the problem and new flooring had been ordered and was due to be fitted in the near future to address the problem.

People were treated with respect and dignity. Staff were compassionate and kind and recognised people’s right to make choices about their daily lives as far as they were able. A small number of staff recruited from overseas had poor English language skills and this meant they were unable to always communicate effectively with people who used the service. The provider was supporting these staff to learn English and there were always staff with good English language skills on shift with them, however this issue needed more monitoring to ensure good communication with people living in the home.

People were offered a range of meals to suit their individual dietary needs and preferences. If they needed assistance with their meals the staff were attentive and offered gentle encouragement at the person’s own pace. However, many people ate their meals while sitting in lounge chairs rather than being assisted to moving to the dining room. We have recommended the provider and registered manager reviews people’s individual seating needs at meal times and seeks further guidance if necessary on supporting people to eat comfortably at mealtimes.

During activity sessions there was a lively ‘buzz’ about the home. Each person’s social needs had been assessed and there was a wide range of activities offered to suit all interests and abilities. An activities organiser was employed on a full-time basis with an advert out for a further activity assistant. A weekly programme of activities had been drawn up which included individual and group activities such as games, arts and crafts People were encouraged to participate in daily routines such as gardening, maintenance, decorating, folding laundry, and cleaning tasks. Even regular activities such as hairdressing had become social events with discussion, music and singing while people waited to have their hair done. During these activity sessions we saw people smiling, happy and relaxed.

People and relatives we spoke with were happy with the care provided. Comments included, “They are all very nice and all respectful” and “The staff seem respectful and get on with each other. They are lovely, very caring, very gentle…everyone is very friendly”. Another relative told us, “They are always very good and respectful. They always respond appropriately to people and difficult situations. I think they do a good job. I am happy with the care”. The provider had sought relatives’ views on the service through questionnaires. People knew how to make a complaint. Where concerns and complaints had been raised we were given assurance these were taken seriously and acted upon promptly.

The provider and registered manager had systems in place to regularly monitor the service and make improvements where necessary.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations (2014).You can see what action we told the provider to take at the back of the full version of the report. We have also made one recommendation relating to seating arrangements at mealtimes.

Is the service safe?

People were treated with respect and dignity by the staff. We saw risks to people's health and well-being were monitored and regularly assessed. Systems were in place to make sure that people's care and welfare was monitored. This reduced the risks to people and helped the service to continually improve. The management team recognised their responsibility to ensure the environment was well maintained and safe.

Is the service effective?

Visitors told us they were happy with the care at the home and we saw people looked relaxed with staff and at ease in their surroundings. People's health and care needs were assessed, and staff knew when to seek external advice when people's care needs changed. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

Is the service caring?

People were supported by friendly and caring staff. We saw that care workers showed patience and gave encouragement when supporting people. People's preferences, interests, aspirations and diverse needs had been recorded and care and support was provided in accordance with people's wishes. People using the service, their relatives, friends and other professionals involved with the service could influence how care was delivered. Where shortfalls or concerns were raised these were addressed.

Is the service responsive?

We looked at people's care plans and we saw the management team contacted health and social professionals appropriately when people's needs changed. When people raised concerns the management team responded promptly.

Is the service well-led?

The service has a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving. Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

We requested information from the home to show how this outcome had been met. We received the information and also evidence from our recent inspection visit in June 2013 (where we did not look specifically at this outcome).

We found that the home was compliant.

We followed up on concerns found at the previous inspection in March 2013 linked to inconsistent care and availability of staff. Concerns included; respecting people, meeting people's mental health needs, promoting continence, providing a clean environment and managing infection control. We received an action plan prior to this inspection.

We found there was improvement, meaning that Barton Place was compliant with the outcomes we looked at and that the provider had taken action to address all the areas of non-compliance. A related safeguarding process is now closed.

We found that overall Barton Place was not consistently meeting people's needs in relation to respecting people, offering choice or meeting care and welfare needs. For example, promoting continence, meeting people's mental health needs, managing infection control issues and providing linen that was fit for purpose. They did not ensure that there were enough staff in the right areas to be able to meet people's care needs in the lounges and meeting people's leisure and social needs.

We also found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the recording and safe administration of some medicines.