Barons Down Nursing Home

Risk management needed improvement to ensure peoples' health and well-being was protected and promoted. We identified shortfalls in respect of the management of risk. For example, the management of incident and accidents. Incident forms were completed but there was a lack of overview, analysis and follow up to prevent a re-occurrence or to mitigate risk. Records were not always clear and accurate regarding people's care and support. Not all staff had the necessary supervision and support to perform their role. The management of medicines was not always safe. Staff were not monitoring the overall effectiveness of pain relief medicine and mood calmers or looking at the times PRN (as and when needed) requests were made for trends or themes. There were not always sufficient, suitably trained and experienced staff deployed.

We have made a recommendation regarding the need to seek advice for the review Deprivation of Liberty Safeguards conditions to ensure they are current and relevant.

People received support from staff who had been appropriately recruited, trained to recognise signs of abuse or risk. One person said, "I do feel safe, the staff are lovely," and "Taken care of, in a kind and nice way I feel very grateful to them all."

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.

The home was clean and well maintained. Infection control procedures were being followed. The staff were kind in their approach and treated people with respect. Improvements had been made to care plans and they were person-centred and relevant to each person. End of life care planning and documentation guided staff in providing care at this important stage of people's lives. Complaints made by people were taken seriously and investigated.

The registered manager and staff team were passionate about the service and their plans to continuously improve and had plans to develop the service and improve their care delivery to a good standard. Feedback

from staff about the leadership was positive, "We will get there, a lot to do though."