Barleycroft Care Home

Updated 10 November 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors, a specialist advisor, and, an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Barleycroft is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was not a registered manager in post. A new manager had been in post since July 2022 and had submitted an application to register with CQC. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection. We reviewed the action plan the provider sent us. We used all of this information to plan our inspection.

During the inspection

We reviewed a range of records. This included 12 people’s care plans and risk assessments, six staff files, staff rotas for permanent and agency staff, health and safety audits, and, medicine administration records (MARs). We also looked at Deprivation of Liberty Safeguards authorisations records and complaints records. A variety of records relating to the management of the service, including policies and procedures were reviewed.

We spoke with the manager, the deputy manager, two nurses, the chef, one kitchen assistant, eight carers, two activity coordinators and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with four people who use the service and four visiting relatives.

We were able to get the views of some people only due to their needs. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not speak with us. Following the inspection, we continued to seek clarification from the provider to validate evidence found, such as policies and action plans. We spoke with 16 relatives to obtain their views of the service. We continued to seek clarification from the provider to corroborate evidence found.

Updated 10 November 2022

About the service

Barleycroft is a care home that provides accommodation, personal and nursing care for up to 80 people across three separate floors, each of which has separate adapted facilities. One of the floors specialises in providing care to people living with dementia. At the time of the inspection, there were 58 people using the service.

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

People had their care needs assessed before they began to use the service. Staff received training to give them the necessary skills and knowledge to help them meet the needs of people who used the service. 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. People were supported to maintain good health. The management team worked with health care professionals to ensure people’s needs were met.

We have made a recommendation about staff supervision.

People's right to confidentiality was protected. Staff had built up good relationships with people and were familiar with their needs and preferences. They treated people with dignity and respect. People were encouraged to maintain their independence wherever possible. The provider was committed to challenging any form of discrimination it encountered. People were encouraged and had an opportunity to contribute and have their say about the care and support they received.

People received care that was responsive to their needs. Care plans provided staff with enough information to enable them to meet people’s needs. Information on how to communicate with people was included in their care plans. There was an effective complaints system available. Comments and complaints people and their relatives made were responded to appropriately. People took part in activities to help ensure they were not socially isolated. They were supported to maintain relationships with their relatives.

We have made a recommendation about people’s care records.

The manager had an open-door policy where people, relatives as well as staff could raise any issues or concerns they had. The provider was aware of when the CQC should be informed of events and incidents that happen within the service and the responsibilities of being a registered provider. There were systems in place to monitor the service and address any areas of improvement where needed. The provider had good links and worked closely with other health and social care professionals to ensure people received the care and support they needed.

Staff understood what abuse was and the actions to take if a person using the service were being abused. Risks to people were identified and care was planned to mitigate the risks. The provider had effective recruitment procedures to make safe recruitment decisions when employing new staff. There were enough staff working for the service to meet people’s needs. People were supported with their prescribed medicines by staff whose competency to administer medicines had been assessed. There were policies and procedures regarding the prevention and control of infection. The provider had a system in place to record and monitor accidents and incidents.

On the day of the inspection, the Wi-Fi connection at the service was working intermittently. This could have an impact on the care and support people receive. For example, there was a delay in people receiving their medicines on time as the provider used electronic medicine administration records. We discussed our concern with the nominated individual who acted immediately to rectify the issue. An appointment was brought forward with the IT company to visit the service and to resolve this on-going issue. The provider also sought advice from the GP as some people had not received their medicines on time.

We have made a recommendation about the provider’s business continuity in the event of infrastructure disruptions.

Rating at last inspection and update

The last rating for the service was requires improvement (published on 25 February 2022) and there were breaches of Regulations 12 (safe care and treatment), 9 (person centred care), and, 17 (good governance). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 2 June 2021. This meant we kept the service under review and, we re-inspected the service within 6 months to check for significant improvements. During this inspection the provider demonstrated that improvements have been made. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.