Barrowhill Hall

Lessons were not always learned after things had gone wrong. Staff recorded when things had gone wrong but the action taken and ongoing risk reduction was not always evident. The provider did not always work effectively with other health professionals or follow professional advice to ensure people’s care was in line with their needs. People felt safe and no one raised concerns with us about how they were supported by staff and staff understood their safeguarding responsibilities. However, the provider did not have effective systems in place to ensure safeguarding concerns were always reported to the local safeguarding authority, as needed. Action and guidance for staff to reduce the ongoing risk of safeguarding incidents reoccurring was not always evident. The provider did not consistently assess and do all that was reasonably practicable to mitigate risks to people.

People’s care plans did not always contain information about risks to people and did not have guidance for staff about how best to support people. Staff knew people well and were able to tell us about people’s needs and different behaviours people displayed. However, some of this information was also not included in people’s care plans, so we could not be sure staff were consistently supporting people in the same way. Medicines were not always safely managed, and in line with guidance. People’s ‘when required’ medicines were not safely managed, and people’s rights and safety were not always protected if they had covert medicines. The home environment was safe, overall. Work was ongoing to replace stained furniture, and the registered manager took action when we highlighted areas which needed improved cleaning. People and relatives were complimentary of the home and grounds. There were enough safely recruited and trained staff to support people, so they did not have to wait long for assistance.

People, relatives and staff were complimentary of the staff team, management team and registered manager. They felt the registered manager was approachable and dealt with issues, if they arose. Staff were able to speak up if they had any concerns and felt able to go to the registered manager. There were regular staff meetings, handovers and supervisions to enable staff to feedback. There was a diverse workforce and staff felt treated fairly at work. Leaders were inclusive, however as there was a lack of effective systems in place we could not be sure leaders were always capable. The governance and oversight systems in place were not effective at identifying concerns or potential improvements to people’s care. Important information about how to keep people safe was missing from people’s care plans or there was conflicting information. There were some instances of undignified terminology used by staff. Systems to monitor medicines were not effective at identifying all issues. The registered manager and provider were responsive to feedback and acted to address areas of concern we identified. The provider was willing to work in partnership with other health professionals; however, professional advice was not always followed which some professionals thought made it harder to work collaboratively. Previous improvements made in the service had not been sustained and as systems were not always identifying deficiencies the provider was not always improving.

The provider was in breach of 3 legal regulations regarding safe care and treatment including management of medicines, safeguarding people from abuse and improper treatment and governance.

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