Barrowhill Hall

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Staff told us about the whistleblowing policy and felt confident to speak up about any poor practice with the registered manager. However, staff told us they were not always confident to speak up to senior management. Governance systems and audits continued to improve since the last inspection. However, some of the audits had not identified the discrepancies we found during this assessment and required further improvement. The provider shared their future innovative plans to grow and develop the home to continue to improve the care and support provided to people.

This service scored 54 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff felt able to raise concerns with their immediate supervisors and the registered manager. However, staff told us they had concerns with senior management. Some staff told us they did not feel able to take concerns to senior management due to feelings of reprisal or job loss. Staff were very positive about the support they received from their immediate supervisors and the registered manager. One staff member said, “The registered manager is a good leader. They are approachable and all staff can raise concerns openly. The registered manager will always act on any concern.” Another staff member said, “The registered manager leads by example. I can raise concerns with the registered manager. They are a very good manager. They are doing their best.” Staff understood and were able to describe the whistleblowing policy. One staff member said, “This is all about reporting poor practice and concerns. I know I can do this with the registered manager, and I know they [registered manager] would treat these concerns seriously.”

The whistleblowing policy was available to all staff, this was stored in the reception area of the home. Staff told us they felt confident to report any poor practice to the registered manager. However, staff told us they did not feel able to take their concerns to senior management. We raised concerns over the culture of the organisation around staff being confident ‘speak up’ and report concerns to senior management, especially if the staff member at the time felt unable to report concern to the registered manager. Members of the senior management team spoke to us about these concerns. They told us there had been employment changes recently which may have unsettled the staff team. The provider reviewed a policy each month with staff, we saw how the whistleblowing policy was this month’s policy.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us governance systems had improved but recognised there was still room for improvement. The provider showed us their action plan from the last Local Authority quality team visit. The registered manager explained how they were working closely with the Local Authority quality team to drive further improvements to the quality auditing processes. The registered manager understood their duty of candour and explained the importance of being transparent, open, and honest. The registered manager responded to all areas of feedback raised during this assessment and developed new systems and processes to improve the quality monitoring of the service.

Quality monitoring processes were taking place and many of these were detailed and had improved since the last inspection. For example, audits of fluid intake clearly identified when targets had not been met and detailed follow-on action taken. Incident analysis and post falls audits identified themes and patterns. Tissue viability monitoring clearly showed when referrals were made. Visiting professionals told us the provider communicated effectively and followed their advice and recommendations. However, improvements were still needed to some areas of the auditing processes. For example, whilst the medicines audit had identified missing signatures and action taken to address this, the audit needed improving to reflect temperatures of the medicine fridge. The training matrix audit needed to action where staff had not completed their specialist training and record follow-on action taken. The care plan audit needed strengthening to include body map recording for one person and to address some of the outdated information we found in care plans. The registered manager was responsive to our feedback and made changes to the auditing process to address the concerns identified. We will review the success of these in the next inspection. Visiting professionals told us the provider had good oversight of the service and worked closely with them to monitor people’s changing needs.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us lessons learnt from incidents and accidents were shared in team meetings. Staff told us they could make suggestions and recommendations to improve the care and support provided to people. One staff member said, “We have regular meetings where we are encouraged to make suggestions to improve the care for people.” Another staff member told us, “During team meetings or supervision, you can make suggestions.” A further staff member told us they had requested additional training from the provider, they told us the provider granted their request. The registered manager shared their action plan with us. This included an application to acquire dementia care association accreditation for the home. The provider told us they were planning an open day during the summer for all people, staff, relatives, and friends to enjoy.

The provider learnt lessons when things went wrong. Incidents and accidents were analysed, and lessons learnt were shared with the staff team. Trends following incidents and accidents were reviewed to identify reduction strategies to lower the risk of recurrence. The provider shared their action plan which set out clear targets to continually improve the care and support provided to people. The provider was in the process of arranging specialist training courses for staff, such as wound ambassador training and oral care ambassador courses. The registered manager explained these courses will improve the skill set of staff. We reviewed correspondence to training providers arranging these courses.