About the service: Barton Place Nursing and Residential Home is registered to provide accommodation for up to 42 people who require nursing and personal care. The home specialises in caring for people living with dementia and mental illness. At the time of this inspection there were 31 people living there.

People’s experience of using this service:

• A new manager had started working in the home a few days before this inspection took place. People, relatives and staff spoke positively about the new manager and told us they had already seen improvements, such as better staffing levels and management structure. . A relative told us “I've met the new manager and things seem to be changing for the better”. A member of staff told us, “We feel absolutely supported by the new manager, [name] Honestly, I feel lucky she accepted this post, she supports us well”.

• Quality monitoring and improvement systems had not been fully effective. In the interim period while the service was without a registered manager some areas such as staff training and supervision had not been carried out effectively. The provider and new manager had plans to implement new quality monitoring systems in the near future.

• People told us they felt safe. There were sufficient staff employed to meet people’s needs safely. New staff had recently been employed and this meant the use of agency staff had reduced. Some gaps in staff training needs had been identified by the new manager and actions had been taken promptly to provide a good level of training to all staff. New systems had been established to ensure all staff receive the supervision and support they need.

• People’s needs had been assessed before they moved in and care plans were in place to ensure staff had information on all aspects of people’s medical, social and personal care needs. Risks to people’s health and safety had been assessed and systems, care and equipment were in place to minimise the risks and ensure people were supported safely.

• People and relatives told us the staff were caring and treated people with respect. Staff were observed sitting and talking to people, and giving people the time they needed. All interactions between staff and people were gentle, kind and respectful.

Rating at last inspection: The service was inspected on 16 and 20 October 2017 when the service was rated as Good.

Why we inspected: Before the inspection we received information and notifications which indicated there may be some areas of concern at the home. These included allegations of missing personal belongings, poor skin care and high staff turnover. Issues relating to poor skin care were resolved quickly. The service had been without a registered manager for approximately three months so we decided to bring the inspection forward by a few months to provide re-assurance the home was being properly managed and providing people with safe care. During our inspection we found there was a new manager in post who had quickly identified areas where actions and improvements were needed and was in the process of taking action to address these. They were working closely with relevant agencies where necessary.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This inspection took place on 16 and 20 October 2017 and was unannounced. At the previous inspection of the home on 19, 23 and 27 September 2016 we found one breach of Regulation 11; Need for consent and we rated the service as Requires Improvement overall. At this inspection we found improvements had been made and the service was fully compliant. We found people were receiving a good service.

Barton Place Nursing and Residential Home is registered to provide accommodation for up to 42 people who require nursing and personal care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of this inspection there were a total of 34 people living there.

There was a registered manager in post. 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.

People told us they felt safe. A relative told us they would not hesitate to report any concerns to the registered manager or deputy manager and said "I feel confident with them". The service protected people from the risk of abuse through appropriate policies, procedures and staff training. All staff had received training and updates on how to recognise and report any suspicions of abuse. Checks and references had been taken up before staff began working at the home. The provider told us new staff were not confirmed in post until they had checked the records to ensure all required evidence was in place and they were satisfied the applicants were entirely suitable.

People and relatives told us there were enough staff employed to meet people's needs safely. Staff rotas showed there were sufficient staff on duty at all times of the day and night. In the last year the number of permanently employed staff had increased, and the number of agency staff had reduced. This meant people were receiving a more consistent service from staff who knew them well and understood their needs.

Risks to people's health and safety had been assessed and regularly reviewed. The home used an electronic care planning system that showed risk assessments had been carried out on all potential areas of risk, for example nutrition, hydration, moving and handling, choking, falls and continence. Staff had a very good understanding of each person's needs and provided care that took account of individual needs and wishes. Staff were able to describe each person's interests, personality, likes and dislikes. They understood people's daily routines and we saw the care plans reflected the care people received throughout the day, which was in line with their care plan.

Medicines were stored and administered safely. People living in the home and their relatives told us they were confident their medicines were looked after and administered safely. Staff were well trained and followed safe procedures when administering medicines. Records of prescribed tablets and liquid medicines were signed for each time they were administered. Medicines were regularly audited to ensure safe procedures were followed.

The home was well maintained, clean and hygienic. Comments from people living in the home and relatives included, "Fantastic. His room is spotless. They didn't know we were coming in today", "Cleanliness seems to be very good. Its clean here, they seem proactive with hygiene.” Equipment such as gas, electrical equipment, hoists, life and fire safety equipment were regularly checked and serviced.

The provider and registered manager had taken actions to ensure people’s legal rights were protected. Where people lacked the capacity to make important decisions about their

The inspection took place on 19, 23 and 27 September 2016. The first day of the inspection was unannounced. The last inspection of the service took place on 4 June 2014 when the service was found to be fully compliant with the standards we looked at.

Barton Place Nursing and Residential Home is registered to provide accommodation for 42 people who require nursing and personal care. At the time of this inspection there were 36 people living there. The home specialises in caring for people with dementia and mental illness. Many of the people we met were unable to hold a conversation due to dementia. We therefore used our observations of care and our discussions with staff, relatives and professionals to help form our judgements.

There was a registered manager in post. 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.

Since the last inspection we received some concerns about the service. These included concerns about continence care, pressure care management, staff training and support, needs, assessments and referrals and moving and handling, low staff numbers, lack of training, poor moving and handling practice, and poor communication skills of overseas staff. Some of these concerns were investigated by the local authority safeguarding team. They carried out investigations and held strategy meetings to discuss their findings and agree actions. The action plans were agreed with the provider who responded pro-actively in a positive way and the safeguarding process was closed a few days before this inspection took place.

During this inspection we heard that the home had recently experienced a period of high staff turnover. They were in the process of recruiting new staff. There had been some changes in the management of the home over the last year. At the time of this inspection a registered manager had recently returned to work in the home after a break in their employment. Their return to Barton Place was welcomed by relatives and staff we spoke with. The staff team spoke positively about the teamwork and communication in the home since the registered manager’s return. We saw evidence of many improvements that had recently taken place in recent weeks to improve the care of people living in the home. Issues that had been raised through the safeguarding process had been, or were in the process of being addressed. During the inspection we identified some further improvements were needed and the provider and registered manager took prompt actions to address these, or put plans in place to address these as soon as possible.

Where people lacked capacity to make an informed decision the records did not always provide evidence of an assessment of their mental capacity. Where restrictions such as bed rails or pressure mats had been put in place we were unable to check that agreement for these restrictions had been reached through a ‘best interest’ process with people who were lawfully acting on their behalf.

People had not always been protected by robust recruitment procedures. Where potential concerns had been raised through one person’s recruitment checks we could not see evidence that a formal risk assessment had been carried out to determine further actions necessary to ensure the applicants were entirely suitable. The new registered manager and provider gave us assurances that in future safe recruitment procedures would always be followed.

There were sufficient staff employed to meet the needs of people living there. Deployment of staff (staff being in the right place at the right time) had at times been a problem, but was improving. Recent staff changes meant that some new staff were still in the process of learning the job. Senior

The inspection was unannounced and lasted over eight hours.

Is the service safe?

People were treated with respect and dignity by the staff. We saw risks to people's health and well-being were monitored and regularly assessed. Systems were in place to make sure that people’s care and welfare was monitored. This reduced the risks to people and helped the service to continually improve. The management team recognised their responsibility to ensure the environment was well maintained and safe.

Is the service effective?

Visitors told us they were happy with the care at the home and we saw people looked relaxed with staff and at ease in their surroundings. People's health and care needs were assessed, and staff knew when to seek external advice when people’s care needs changed. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

Is the service caring?

People were supported by friendly and caring staff. We saw that care workers showed patience and gave encouragement when supporting people. People's preferences, interests, aspirations and diverse needs had been recorded and care and support was provided in accordance with people's wishes. People using the service, their relatives, friends and other professionals involved with the service could influence how care was delivered. Where shortfalls or concerns were raised these were addressed.

Is the service responsive?

We looked at people's care plans and we saw the management team contacted health and social professionals appropriately when people's needs changed. When people raised concerns the management team responded promptly.

Is the service well-led?

The service has a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving. Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

We completed a desktop review of the outcome 24, Suitable management of services is provided, to clarify that this outcome had been met. When we visited the home in October 2012 we made an improvement action relating to the appointment of a manager/appropriate person as at the time there was no manager employed although the home were actively recruiting.

We requested information from the home to show how this outcome had been met. We received the information and also evidence from our recent inspection visit in June 2013 (where we did not look specifically at this outcome).

We found that the home was compliant.

This inspection was carried out in direct response to concerns raised by a number of relatives of people who lived at the home. Their concerns related to staffing levels and whether the needs of people living at the home were being met. We visited unannounced on three separate occasions over an extended period. This was because of the amount of information received from relatives, other health professionals, and from an investigation by the multi-disciplinary safeguarding team during which all the people living at the home were reviewed.

We heard that the previous manager had left and that 10 days before our visit a new interim manager had started. We saw that the new manager had identified that staff in general had not had regular formal support and supervision relating to their performance for some time. She had started to address this issue and discovered some shortfalls in staff competency and knowledge, which she contacted us about.

One inspector visited the home on 20 October 2011 in the afternoon, and two inspectors visited on a further two occasions. On 29 November 2011 we visited all day, to include early morning staff handover period, breakfast and tea time; on 14 December 2011 we visited in the afternoon. Since our final visit for this inspection the home has shown us their improvement plan and kept us updated on progress. We will continue to monitor progress using our compliance processes.

There were 24 people living at the home on the first visit. One person was in hospital. Many people living at the home were not able to comment directly on the service itself because of their memory problems. We spent time observing care throughout the home. This enables us to make judgments about how people occupy themselves during the day, and the skills of the staff who support them.

When we looked around the home on our arrivals, we heard staff talking in a kindly way to people as they assisted them, explaining what they were about to do and so on. However, we heard some conversation that was patronising and not respectful to people such as using ‘good girl’ and ‘babe’ etc. The manager had addressed this issue recently with the relevant staff.

Some people were being offered choices for their breakfast, some were not. We were told that the system in place to provide breakfast for people using the service was based on people’s choice. However, we found that records did not show what choices the people living there may have made when they were more able to communicate their needs and preferences. We did not see consistent care records to aid staff in finding out people’s choices. Staff were verbally asking people whether they would like to get up or what would they like for breakfast, but the majority of people were unable to understand unless given clear prompts or time to respond. Therefore, breakfast went on until after 11.30am. There was no organisation or structure around breakfast and helping people to get up to ensure that it was timely.

Staff all told us that there were not enough staff to meet people’s needs during our first two visits. One floor was unattended for long periods whilst staff worked on the top floor and worked their way down. One new staff member was ‘minding the lounge’. However, they did not know about people’s needs when asked. We listened to a staff handover which was a quick list of people saying that they were ‘ok’ or about their bowel habits. Some staff had not been on duty for a week. We did not see any staff refer to care plans. Staff told us that they did not have time. Care workers who were not nurses told us that they did not have input in care planning. Care records did not fully explain to staff what people’s needs were. For example, one person should have been mobilising every day with assistance to prevent stiffness. This was not happening, as confirmed by their relative; staff told us that they did not have time and had recorded this in the care records.

We asked the manager to provide us with information about people’s dependency levels. We saw from this that there were high levels of dependency. We saw that people were sat with cold food for long periods and that staff were extremely busy. On one occasion two staff were sent for their lunch break together, resulting in the last person being assisted to get up at 1.20pm. Lunch was provided at 12.30pm, which for some people was very soon after their breakfast. Staff did not note who had eaten what when, meaning that some people had lunch and breakfast close together; others who had refused meals all morning were not monitored, and on one occasion the review team had to point this out. We found that during the period of change in the home’s management that there were not enough staff to ensure that people’s needs were fully met by staff with the appropriate skills.

People living at the home did not receive meaningful engagement or interaction on a regular basis. During our period of observation in the lounge, we noted that staff interacted more with some people than with others. Two people, who were quiet, were not spoken to for over two hours in the lounge. We observed that some individuals were not given the opportunity or encouragement to move from their chairs for over three hours. There was one activity co-ordinator on the first and second visit, who engaged very well with people but who was unable to engage with everyone due to numbers. Other staff only engaged with people during tasks or for brief chats.

Records showed that people and their advocates had limited opportunities to be involved in making decisions about their care and the life of the home. Relatives told us that as a large number of relatives had raised concerns they had requested a group meeting to discuss matters. There were no organised meetings for relatives. The home eventually held a meeting in December after this was raised within safeguarding meetings. The manager had offered individual meetings and some relatives had taken this up, but some relatives felt that they needed the support of other relatives due to their concerns. Relatives regularly reported that if they had a query about someone living at the home, it was difficult to find staff to ask. One relative waited told us that they had been asking about someone’s weight over three days before finding staff who could help. Relatives told us that there were a lot of changes, such as the introduction of a new manager, and that they did not know what was going on. However, annual questionnaires had recently been sent to individuals or their advocates, seeking their views on aspects of the service in September. Feedback at that time was generally good from relatives.

The service also had systems in place to identify, assess and manage risks to individuals at the home, such as in relation to risks of falling, pressure sores, and nutritional assessments. These risk assessments informed care plans for people's care and treatment, aiming to promote their welfare and wellbeing. But staff that we spoke to or followed did not know about the risk assessments. Staff told us that this was due to time pressures. Audits of falls and behaviours had not been used to develop personalised action plans, to identify triggers and devise care plans to minimise falls.

Two compliance inspectors and a pharmacy inspector visited Barton Place unannounced on February 29th 2012 at 09.30-17.30. We were visiting to follow up concerns raised by relatives, staff and the multidisciplinary safeguarding team and to assess improvement. The safeguarding team had been closely monitoring the delivery of care at Barton Place on a mainly daily basis since November 2011. Concerns had been identified during our previous inspection, which took place unannounced over three days during October, November and December 2012. During this time we asked the Provider to suspend further placements to the home, which was voluntarily agreed. This arrangement has now been lifted as overall we found Barton Place to be compliant, at the time of this inspection, with each of the assessed outcomes. Concerns from the previous inspection and from the safeguarding team related to; communication between the home and relatives and staff, safeguarding, staffing levels and care and welfare of the people living there. We received regular updates from the Provider and a comprehensive action plan and we have asked that these updates continue for the time being on a weekly basis.

Since the concerns were raised with the home there have been many changes to how the home is run as the service worked towards improvement. This initially impacted on the care and delivery of the service as there was a high level of staff turnover and system changes, some outside the home’s control. We saw that the home failed to provide adequate care for two people who have since moved from the home. Due to this we have imposed improvement actions for each outcome to ensure that improvements are sustained and that peoples’ needs are met. During this inspection we found that the Provider had invested time and finances into improving the service and communication between the management and staff and relatives. We found the Provider was currently making improvements to the environment, working to strengthen the permanent staffing team with the support of external specialists and acting to improve record keeping and auditing systems to ensure that peoples’ needs are identified and met. These processes are new and during the inspection appeared to be effective but we will monitor progress.

There were 19 people living at the home at the time of our visit. Most people living at the home were not able to comment directly on the service itself because of their memory problems. We spent time observing care throughout the home. This enabled us to make judgments about how people occupy themselves during the day and the skills of the staff who support them.

We spoke to three relatives, nine staff and spent time with people living at the home on a one to one basis. We spoke in depth to the Provider, acting clinical lead and the manager from a sister home who was assisting in managing improvements. We inspected all areas of the home including all the accommodation, communal areas and the kitchen. We ‘pathway tracked’ six people living at the home. This means that we spent time with them and we looked at records that the staff had completed about them and we spoke with duty staff who were specifically supporting them with their care needs.

A relative commented that "staff do a really good job and everybody thinks extra staff have been brought in. The activities workers are friendly faces". When asked what had improved they said that basic care needs were met and there was a better atmosphere in the home.

Overall, we found that improvements had been made to ensure that peoples’ needs were met but as there has been a period of change in the staff team and systems we will continue to monitor improvements using our compliance methods.

Our visit was unannounced and took place over one day with two inspectors. At the time of the inspection the majority of the 25 people living at Barton Place had dementia and/or complex care needs, and therefore not everyone was able to comment directly on the service. However, we met with 10 people living at the home and two relatives. We also spoke with the provider, clinical lead nurse and eight staff. We spent the majority of our time observing care in communal areas and used a tool called SOFI 2 (Short Observational framework for Inspection) to help us make a judgement about people's experiences of using the service. We looked at six care plans for people living at the home, staff rotas, care and quality assurance records.

We followed up on concerns found at the previous inspection in March 2013 linked to inconsistent care and availability of staff. Concerns included; respecting people, meeting people’s mental health needs, promoting continence, providing a clean environment and managing infection control. We received an action plan prior to this inspection.

We found there was improvement, meaning that Barton Place was compliant with the outcomes we looked at and that the provider had taken action to address all the areas of non-compliance. A related safeguarding process is now closed.