Barton Brook Care Home

The assessment was prompted in part by notification of an incident following which a person living in the home, sustained a serious injury and subsequently died. This incident is subject to a criminal investigation by CQC and as a result this assessment did not examine the specific circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk in relation to falls, staffing levels, staff training and leadership and management. This assessment examined those risks.

The provider did not always make sure the right skilled and experienced staff were deployed to meet people’s needs. They did not always make sure staff received effective support and supervision.

Medicines and treatments were not always safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning their medicines.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive.

The provider sought to ensure people’s care and support was effective by assessing their health, care, wellbeing and communication needs with them.

The provider did not always plan and deliver people’s care and support that was in line with evidence-based good practice and standards.

Staff treated people with kindness, empathy and respected their privacy and dignity. During the onsite element of this assessment, we observed care and support being provided to people in communal areas. We observed some positive interactions between people and staff.

Whilst we acknowledge the new leadership team was beginning to make improvements around the culture across the home, further time was required to ensure these were fully embedded and improvements sustained. Critical to achieving success, is a stable leadership team, with a manager registered with CQC who can lead by example, operating effective systems and processes to support good governance.

At this assessment we found one breach of legal requirement in respect of good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.