Barn Park Residential Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

There were breaches of regulation 12 (Safe care and treatment) and 13 (Safeguarding service users from abuse and improper treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Known safeguarding risks were not well assessed, monitored, or managed which put people at risk of harm. Risk assessments were not always effective. Care plans did not provide adequate guidance to staff to reduce the risk of reoccurrence. People looked at ease with staff. Visitors were positive about the staff group and how they interacted with their relatives. The majority of the staff were positive how staff were deployed on each shift; some staff expressed frustration about the disrespectful attitude of some staff towards others. Aspects of medicines administration, management and storage were not safe. Infection control was well managed. Records had not been kept of completed refurbishment work or planned improvements to the home; this meant there were no written timescales to show how work was being prioritised.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Known safeguarding risks were not well assessed, monitored, or managed which put people at risk of harm. Care records showed there were incidents between people living with dementia, for example due to people misunderstanding their relationships with others. One person’s records showed there were multiple safeguarding concerns linked to their safety. Some people were aware there have been concerns with their relative’s interactions with others but felt staff handled situations well between people living with dementia.

Staff were able to explain what triggered some people living with dementia to become upset or frustrated. They described what actions they would take to prevent an incident escalating. For example, recognising one person living with dementia was protective of other people and could misread staff intervention as a threat to the another’s safety. Staff said they understood their safeguarding responsibilities and were aware of internal and external reporting processes.

Safeguarding incidents were not routinely notified to the relevant authorities, such as the local authority safeguarding team and CQC. This meant there was no oversight from external agencies to ensure staff were responding appropriately and keeping people safe. Records did not contain enough information to enable staff to mitigate risks to people. Safeguarding events were not consistently documented to allow for patterns and quantity to be audited so action could be taken to reduce risk to people living and working in the home. Risk assessments were not comprehensive and care records lacked guidance for staff. For example, in one person’s ‘Aggression Physical’ section, it describes how the person can be ‘very aggressive and physically aggressive when he becomes frustrated. There was no detail of what situations made him frustrated. There was no guidance as to how to reduce the situation from happening or how to respond.

Relatives told us there was good security and the risk of falls was well managed, with staff working alongside people living at the home. For example, one person said, “[Person’s name] needs more physical guidance now when moving around and I have watched them with her. They do it really well, they explain things to her and move slowly. She used to fall regularly at home but hasn’t had any falls here, so that tells me they are doing everything to keep her safe.” However, one person’s actions and words had demonstrated their wish to leave. Despite this known risk, there was an unalarmed door in their room which went into the garden. Staff said the garden was secure but had not considered the risk of the person going into the garden at night without their knowledge, and potentially coming to harm.

Staff said they were updated on changes to people’s safety and well-being. They told us about incidents and how they responded to them. Verbal handovers took place, but these were not recorded so could not be reviewed to remind staff or update them of new risks to people’s health and well-being. Staff were directed to care plans to read updates, but we saw care records were at times unclear and identified risks were not addressed.

Staff practice showed they knew people well. In communal areas, some people expressed irritation and frustration towards others due to their behaviours, such as constantly changing seats or encroaching on their personal space. Staff were not always present in communal areas to intervene and reassure people. This meant there was the potential for people to be harmed or become anxious about their safety.

Risk assessments were not effective. The assessment tools were not nationally recognised and some of the information was contradictory. Care plans did not provide adequate guidance to staff to reduce the risk of reoccurrence. For example, the risk of self-harm for one individual. There was no risk assessment to show what actions had been put in place to reduce the known risk. Safeguarding risk assessments had not been regularly reviewed so did not show how risks were monitored, and if risks had changed. For example, people’s risk assessments showed reviews did not take place over 4 months in 2023. While care records for January 2024 had multiple gaps including for personal care and meals.

Relatives gave mixed feedback on the appearance of the home; some liked that it was “homely” and “old-fashioned”, but others said, “The home could do with updating” and, “The home is tired and could do with a lick of paint, I have seen mould on some of the walls.” In the dining room where people and staff ate their meals, there was black mould on the walls, paint work and curtains. During the assessment people commented to each other they were cold; they were rubbing their arms and legs to warm up. They encouraged each other to sit near a heater. A staff member also commented it was cold and increased the heating. Some people were given blankets to keep warm.

The provider said they continued to invest in the maintenance of the home, including double glazing to the front of the house, a new kitchen, new chairs, and new laundry equipment. During the assessment, improved lighting was fitted in a dark upstairs corridor and after the assessment we were told a window had been added to one of the lounges to improve the light. The provider said the extension used as a dining room would be replaced with an updated conservatory.

The provider had not kept records of completed refurbishment work. Planned improvements were not recorded; this meant there were no written timescales to show how work was being prioritised. This also meant we could not judge how long people would be impacted by the work or how long they would have to wait for improvements. Since the assessment, the provider has sent us a list of previous and planned work to the home. Environmental checks, such as hot water checks, were completed. However, the environmental temperature was not monitored. Following feedback during the assessment, thermometers were distributed around the building, which the manager said they would check, and the timing of heating settings were increased.

People looked at ease with staff. Visitors were positive about the staff group and how they interacted with their relatives. None of the visitors raised concerns about the staffing levels. For example, they said, “The staff are lovely, very polite and make me feel welcome” and, “Whenever I phone up the staff are always very pleasant and as far as I am aware she is being well looked after.”

The majority of the staff were positive how staff were deployed on each shift, although some said there could be better teamwork between some staff members. Some staff expressed frustration about the disrespectful attitude of some staff to others in the team. There were no records to show how poor performance had been addressed with the individuals. The provider and manager said they were aware of alleged discrimination by some staff members and had begun to address the issue.

Staff were responsive to people’s care needs but there was little social interaction or stimulation.

Staff rotas were maintained; we saw they reflected the care staff on duty. However, a dependency tool was not used to judge the level of support needed for each individual. This meant when people’s care needs changed there was not an audit trail to show how this had been reviewed and the potential impact on the availability of staff. The manager told us they were reviewing the training matrix as it was not accurate. We saw there were many gaps on the matrix, but individual staff files showed they had completed additional training, for example online. Staff were positive regarding their access to training.

Visitors said the cleanliness was generally good, including people’s bedrooms. The flooring in one person’s room had been replaced to make it easier to keep clean and reduce odours. The person’s relative said this was an improvement.

There was one housekeeper. When they were not available, care staff also covered basic cleaning tasks alongside their caring role.

Care staff were responsive to cleaning incidents. For example, one person was incontinent in a communal area; care staff quickly responded to the incident and cleaned the carpet without drawing attention to their task.

Since the assessment, an external agency has completed an infection control audit at the service. The manager said there had been a positive outcome with no concerns; this was confirmed when we reviewed the professionals report.

One relative said, “Her medication is controlled better in the home than when she lived on her own. There haven’t been any issues and they have got her to take it regularly which is excellent.” Other relatives did not have a view on medicine management.

Staff told us they received medicines training; competency checks were not recorded to show they gave medicines safely. After the assessment, the manager said external training would take place to enhance staff knowledge.

There was a failure to create effective systems to ensure there was safe management of medicines. For example, some medicines were not routinely securely stored and were available to all staff accessing the office and not just those authorised to handle medicines. Following the assessment, the manager said they had addressed all the concerns connected to medicine administration, management and storage.