We inspected the service on 23 February 2018. The inspection was unannounced. Barnfield Manor is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Barnfield Manor accommodates 39 people living with nursing needs, dementia and conditions related to old age. On the day of our inspection 22 people were living at the service.

At the last inspection, in 23 November 2015 the service was rated overall as ‘Good’. At this inspection we found that the service remained ‘Good’.

Since our last inspection there had been a change of registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were supported by a staff team who understood their role and responsibilities to protect them from abuse and avoidable harm. The registered provider had systems, policies and processes to support staff in safeguarding people. Staff had received appropriate safeguarding training.

Risks to people’s safety, including the environment had been assessed and were monitored and reviewed.

People’s medicines were administered, stored and managed safely.

The service was clean and hygienic and staff had received training in the prevention and control of infections and a policy and procedure was available to support staff.

People’s needs had been appropriately assessed and staff had information of the support people required to effectively manage their needs. Staff had received induction, training and support. Some gaps were found in staff training, this had been already identified in some areas and training booked.

People received a choice of meals and drinks and their dietary needs were known and understood by staff. People were supported to access primary and specialist health services to monitor their health needs. Staff worked with external healthcare professionals to secure good outcomes for people. The internal and external environment was appropriate for people’s individual needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible, the policies and systems in the service supported this practice. This included how they wanted to spend the time towards and at the end of their life.

People were supported by a staff team that knew them. Staff were caring and provided a person centred approach. Independence was promoted, dignity and privacy respected and people were involved in their care and support. People had access to independent advocacy information should they have required this support.

Staff supported people with their interests and hobbies and people or their representative contributed to planning the care and support they received. People’s communication needs had been assessed and planned for. The provider’s complaints procedure had been made available for people and was presented in an appropriate format. People’s end of life wishes had been discussed with them.

People, relatives and staff were positive about the leadership of the service. People received opportunities to share their experience about the service they received. Systems and processes were in place to monitor the quality and safety of the service people received.

This inspection was unannounced and took place on the 23 November 2015. .

Barnfield Manor provides accommodation, nursing and personal care for up to 39 older adults. This includes most people who are living with dementia at Barnfield Manor. There was a registered manager at this service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in October 2014 we found that people were not always protected from unsafe or inappropriate care and treatment or from receiving care without the consent of a relevant person. This was because people’s health, mental capacity and medicines needs were not always properly accounted for or safely managed and staffing arrangements were not always sufficient. Also, the provider’s arrangements for monitoring and improving the quality and safety of people’s care, did not always ensure people’s health, safety or welfare. These were respective breaches of Regulations 9, 11, 12, 18 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following that inspection, the provider told us what action they were going to take to rectify the breaches. At this inspection we found that this was achieved as significant improvements had been made.

Further improvements were needed because the provider was not always proactive in determining or making service improvements, initiated by local authorities or interested parties outside the service.

People and their relatives were satisfied that people were safe in the home. The provider’s arrangements helped to protect people them the risk of harm and abuse.

Staff recruitment and deployment procedures helped to make sure that staff were fit to work at the home and that staffing arrangements were safe and sufficient to meet people’s needs.

People’s medicines were safely managed and people received their medicines when they needed them.

The provider’s emergency contingency planning and equipment arrangements helped to promote people’s safety at the home.

Staff supported people safely and they understood risks to people’s safety associated with their health conditions and the care actions required for this mitigation.

People received the care they needed and were supported to maintain and improve their health and nutrition.

People were supported to access external health and social care professionals when they needed to and staff followed their instructions for people’s care when required.

The provider’s arrangements helped to make sure that people received care from staff that were appropriately trained and supported.

Staff followed the Mental Capacity Act 2005 (MCA) to obtain people’s consent or appropriate authorisation for their care.

Staff treated people with respect and kindness and promoted their dignity, privacy, choice and independence.

People and their relatives were appropriately involved and informed in the care provided and staff established supportive relationships with them.

Staff supported people to maintain their known daily living preferences and their personal routines interests and beliefs.

Staff supported people to interact and engage with others in a way that was meaningful to them.

The views of people using the service or with an interest there, together with concerns and complaints received, were used to inform and make service improvements.

People, relatives and staff found the registered and senior managers accessible and approachable and were positive about overall about the direction and improvement of the service.

Staff understood their roles and responsibilities for people’s care. The provider’s arrangements for the management and day to day running of the home and improvements in progress, helped to support staff performance and improvement.

Accommodation, nursing and personal care, is provided at this location for up to 39 older adults with nursing needs or living with dementia. At our visit, 28 people were living in the home. There had not been a registered manager in post at this service since August 2014.

There was no registered manager in post. A new manager had been appointed who advised they were commencing their registered manager application. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

There were not always enough staff to meet people’s individual care needs and people did not always receive appropriate care or treatment. People were not being fully protected from risks associated with unsafe medicines practice because their medicines were not always properly stored, recorded or given.

Staff, were aware of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), but they did not fully understand or follow these when required. They did not always show whether people’s capacity to consent to their care had been properly considered or authorised, when restrictions to people’s freedom had been made to keep them safe.

Before our visit the provider told us they carried out regular checks of the quality and safety of the environment and people’s care. However we found that their checks were not wholly effective to protect people against the risks of inappropriate or unsafe care and treatment because they were not always being followed or acted on. The provider’s checks had not been consistently or proactively undertaken, which resulted in failure to identify and act on areas of concern for people’s care that we found at this inspection.

People, their relatives and most staff felt that people’s care and staffing arrangements were improving, but that staffing arrangements were not always sufficient to ensure people’s safe supervision and delivery of their care.

Staff received most of the training they needed to perform their role and responsibilities. Plans for further staff training covered most, but not all of the areas outstanding for a few staff members.

People and their relatives felt that overall, staff had established, caring and supportive relationships with them and often consulted with them about the care they provided. Most said that staff ensured people’s dignity and treated them with respect and kindness. Relatives and friends said they were made to feel welcome and comfortable when they visited the home. During the course of our inspection we saw that staff, were often caring, compassionate and respectful towards people. However, we observed some instances when staff did not always ensure people’s equality, independence, dignity or choice. We have recommended that the provider continues to review and develop there are approach to meet with recognised guidance for ensuring people’s equality and rights in their care.

People were supported to eat and drink and to maintain a balanced diet. People’s body weights were monitored and they were given foods in the consistency they required. This helped to make sure that people’s nutritional needs were being met. New menus were also being introduced in consultation with people to improve the choice of food provided, as this had been limited, particularly for people who required a soft diet because of their medical condition.

People who were able to express their views, relatives, local commissioners and some staff told us that the management of the home had not been consistent or pro-active before our inspection. All said that since the manager’s appointment, they were pleased or satisfied with some of the improvements that were being made for people’s care. People and their relatives knew how to raise concerns or to make a complaint.

Programmes for regular staff meetings and individual staff supervision had commenced. Staff understood their roles and responsibilities for people’s care. Staff knew how to raise any concerns they may have about people’s care and expressed their on-going commitment to maintaining and improving this.

Improvements had been made to protect people from harm or abuse. This included the formal monitoring of some of the known risks to people from their health conditions and the monitoring of complaints, safeguarding concerns and accident and incidents, such as pressure ulcers and falls. There were clear procedures in place for reporting the witnessed or suspected abuse of any person using the service and staff that we spoke with knew and understood these.

Contingency plans were in place for staff to follow in the event of unforeseen emergencies in the home. Since our visit the provider has assured us of some additional measures they were taking for fire safety in the home.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which correspond to a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Almost all of the people living at Barnfield Manor were living with dementia and as such were not able to have meaningful conversations with us about their experiences or feelings. We have therefore used Short Observational Framework for Inspection (SOFI) to inform our judgements. SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

During our last inspection in January 2013 we found that people’s care and treatment was not always planned in a way which met their individual needs. We also found that the provider did not have appropriate arrangements in place for the management of medicines.

There were 27 people living at Barnfield Manor at the time of our inspection. This included one person who moved into the home on the day of our visit. We observed that people were not always receiving appropriate support and supervision from staff.

We found that people's care and treatment were not consistently planned and delivered in a way which met their needs or protected their safety and welfare. People’s care plans did not always reflect changes to their needs.

We also found that most of the improvements that had previously been made in the safe handling of medicines had not been sustained. We found that people did not always received their medicines because they were out of stock and that people's medicines records were not completed correctly.

Following our last visit to Barnfield Manor on 22 October 2012 we issued a warning notice in respect of the management of medicines to ensure that improvements were made quickly in order to protect people. We also found that people living in the home were not consistently being given opportunities to be involved in their care or treatment and that people’s care and treatment was not always being delivered in a way which met their individual needs.

There were 24 people living at Barnfield Manor at the time of our visit. During our visit we found that some improvements had been made with regards to people’s involvement in their care and the way people were receiving their medicines. However we found that the arrangements for the management of medicines did not protect people living in the home.

We found that since our last visit, the new manager and staff had spent time with people living at Barnfield Manor discussing their care and where possible obtaining their views. This had been done in a way which ensured that, as far as possible, people expressed their views and were involved in making decisions about their care and treatment.

Almost all of the people living at Barnfield Manor were living with dementia and as such were not able to have meaningful conversations with us about their experiences or feelings. We have therefore made most of our judgements based on discussions with people’s relatives and also our Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

There were 24 people living at Barnfield Manor at the time of our visit, plus one person who was receiving respite care. We found that the atmosphere throughout the home had improved since our last visit in June 2012. We observed that over lunchtime it was much more relaxed and everyone sat at tables and ate their meals without becoming distressed or anxious.

We spoke with the relatives of three people living in the home. One person said “the home has improved, there are still a few niggles like with laundry, but (the provider) seems to be addressing them”. Another person told us “I’ve been in to review (my relatives) care plan and they’re keeping us informed.”

A pharmacist inspector from the Care Quality Commission also visited the home. We found that some minor improvements had been made but overall people were still not protected against the risks associated with the unsafe use and management of medicines.

We have spoken to a number of the relatives of people living at Barnfield Manor as part of us reviewing the improvements made to the service.

Everyone we spoke with told us that they are now receiving more communication from the provider about their relatives care. People said that they were generally happy with the work being done to improve the service being provided in the home.

We have spoken to a number of the relatives of people living at Barnfield Manor as part of us reviewing the improvements made to the service.

Everyone we spoke with told us that they are now receiving more communication from the provider about their relatives care. People said that they were generally happy with the work being done to improve the service being provided in the home.

Barnfield Manor Care Home provides a specialist service for people with dementia and as such it was not possible for us to have meaningful discussions with people about their experiences or views of the service.

During our visit we observed staff interacting positively with people living in the home. People were given support and encouragement at mealtimes. We saw people were smiling and laughing with staff.

We spoke with the relatives of three people living at Barnfield Manor Care Home. Everyone we spoke with agreed that the provider had made and were making improvements in the cleanliness and hygiene in the home.

One person told us “the home has started to make changes and it is much cleaner”.

We did not talk to people about their medicines during our visit. We observed how they were given their medication and we spoke to the nurse administering medicines. We also looked at records of their medication and the medicines which were in the home.

We spoke with five relatives of people using the service. Most of them told us they felt people’s dignity, choice and independence were not always met, or fully respected.

They generally described the staff in the home as friendly and caring however they felt that there were not enough staff to meet people’s needs. We were told “staff are brilliant, there’s just not enough of them” and “there are always lots of new faces when I visit”.

People told us that they were worried about the cleanliness of the home.

People also told us that they were unaware of the complaints procedure in the home and that they had felt unable to raise concerns with the provider as they were worried about the effect it would have on the care being provided to their relative in the home.

At our visit there were 16 people accommodated, both male and female and all with significant dementia and nursing care needs. This meant we were unable to hold in depth discussions with people due to their individual given mental capacities.

In addition to the methodology identified at the beginning of this report and to further assist us in determining peoples’ experiences of the care and support they received, we undertook focused observations of staff interactions with four people. These covered a period of one hour in the main lounge area during the morning of our visit, using our Short Observational Framework for Inspection (SOFI).

We repeated the same at lunchtime in the main dining room for a 30 minute time period. During those time periods, we also made general observations relating to staff interactions with other people accommodated.

Our focused observations during the morning time periods found that the majority of staff interacted positively with people at all times. Conveying warmth, acceptance and respect. Promoting people’s privacy, dignity, belonging and inclusion. Those staff were also seen to adopt a relaxed pace with people and to recognise and support their individual reality.

We found for some of the time periods that we observed during the morning, where two staff’s interactions with people were found to be of a negative type, including ignoring them. We discussed our findings with the manager, who has since informed us of suitable action they have taken about this.

We saw staff interacting with people to assist in meeting their social needs and observed that people were supported by way of a calm social setting at lunchtime. During which, staff recognised people’s skills and provided the support they needed.

Comments received from people’s relatives via a satisfaction survey conducted with them in May 2011 by the home included,

‘Staff, display a caring and helpful approach.’ ‘My mother’s needs are met.’

‘Activities are adequate.’

‘Food is excellent and varied.’

Most of the people living at Barnfield Manor were living with dementia and as such were not able to have meaningful conversations with us about their experiences or feelings. We have therefore made our judgements based on our Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

At our last inspection of Barnfield Manor on the 29 April 2013 we found that people were not consistently receiving care that met their needs and protected their health and wellbeing. We also identified on-going concerns around the management of people’s medicines. Staff were not receiving support to deliver care and treatment safely and to an appropriate standard.

There were 22 people living at Barnfield Manor at the time of our inspection. We found that improvements had been made to all aspects of the care people were receiving. We observed that people were being asked for their consent before receiving support and that people, and their relatives, were being involved in decisions relating to their care.

People were receiving care, treatment and support which met their needs and their care plans were being kept up to date. Staff had received additional training and were undertaking regular supervision and an appraisal.

There were effective systems in place to assess and monitor the quality of service that people received.