What life is like for people using this service:

• People who live at Barking Hall have their needs met by sufficient numbers of suitably trained staff. We observed people’s requests for assistance being answered promptly. Staff were kind and caring towards people and knew them as individuals.

• The environment was comfortable and safe. There was dementia friendly signage making it easier for people to find toilets, the dining room(s) and lounges.

• People were supported to remain engaged and had appropriate access to meaningful activity. There was a range of activities on offer to suit people’s preferences, including weekly trips.

• People were offered a choice of good quality, nutritional meals. People were provided with appropriate support to reduce the risk of malnutrition or dehydration.

• People received the support they required at the end of their life. The manager had plans in place to enhance end of life care planning.

• The service worked well with other organisations to ensure people had joined up care. People were supported to have input from external healthcare professionals.

• People and their representatives were involved in the planning of their care and given opportunities to feedback on the service they received. People’s views were acted upon.

See more information in Detailed Findings below.

Rating at last inspection: Requires Improvement (report published 31 January 2018)

About the service: Barking Hall provides accommodation, nursing and personal care for up to 49 people who require 24 hour support and care. Some people were living with dementia. At the time of our visit 42 people were using the service.

Why we inspected: This was a planned inspection based on the rating at the last inspection. The service has made sufficient improvements to be rated Good.

Follow up: Going forward we will continue to monitor this service and plan to inspect in line with our reinspection schedule for those services rated Good.

This comprehensive inspection took place on 31 October 2017 and was unannounced.

At our last inspection of 27 September 2016 we rated the service as ‘Required improvement’ and the areas in need of improvement were person-centred care and the safe care and treatment of people. There were issues with having sufficient staff on duty to meet people’s needs. The systems in place for the oversight and managements of risks were not working effectively and this meant that people were at risk of poor care.

Following the last inspection, we met with the directors of the service to confirm the situation and asked the service to complete an action plan to show what they would do and by when they would have improved upon the key questions of Safe and Responsive to achieve an at least ‘Good’ rating in those key questions.

The service sent an action plan stating the action to improve would have been completed by 7 January 2017. Although we found some improvements at this inspection we did not find sufficient improvement to rate the service as good in answer to those key questions and found other areas of concerns detailed in this report.

Barking Hall Nursing Home is registered to provide nursing 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.

The service can provide nursing care for up to 49 people. On the day of inspection there were 42 people using the service.

At the time of this inspection, the service did not have a registered manager. The service was being managed by a relief manager who was also managing another 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.

Managers had been appointed since our last inspection but left before becoming registered.

Improvements relating to the individual risk documents were not always completed accurately

Although the staff we spoke with knew people well the service did rely regularly on the support of agency staff who would not know people’s needs in detail. Care plans were lacking detail with regard to moving and handling people and therefore people and staff were placed at potential risk due to lack of clear instruction.

Accurate records of people’s care were not always maintained. Although repositioning charts were completed people’s care plans did not provide sufficient guidance to staff on people's needs. We identified gaps in how people's needs were monitored in order to help people maintain their health and wellbeing. People were placed at risk of pressure ulcers not being effectively managed. There were gaps in people’s records of when their dressing were planned to be changed.

The service used a system called resident of the day so that once per month peoples care records were audited for completeness and accuracy. We found this system was failing at times as there were no records that the care plans had been checked and updated.

People told us that there were insufficient staff to meet their needs in a timely way. The dependency tool in use had not been fully completed therefore we could not be sure there were sufficient staff employed at the service to meet people’s needs at all times. The nursing staff administering medicines took over two hours to complete the morning medicine round to all of the people at the service.

Staff had received training to identify the various types of abuse and knew how to report any concerns. There were robust recruitment processes in place and people’s medicine records were detailed.

Staff had received supervision, regular training and an appraisal. People were provid

The inspection took place on the 27 September 2016 and was unannounced. Barking Hall Nursing Home provides care and accommodation for up to 49 older people. There were 43 people living at the service on the day of our inspection. The previous inspection of 25 November 2015 found that the service required improvement. There was a breach in regulation in relation to staffing levels and this inspection was undertaken to follow up on this area.

The service has a new registered manager who had been appointed since the last inspection. 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.

We found that there were continued issues with staffing levels. Since the last inspection the provider had increased the levels of staffing but the needs of the people living in the service had also increased and this meant that the levels were no longer adequate. The manager and the regional manager assured us that they had already identified that further staff were needed to meet people’s needs. We received confirmation, in the days following the inspection, that the staffing had been increased and that there were contingency arrangements in place to deal with events such as staff sickness. There were clear arrangements in place to check on staff suitability as part of the recruitment process.

The systems in place for the oversight and managements of risks were not working effectively and this meant that people were at risk of poor care. Medication was not consistently well managed so for example, people were not always receiving creams and lotions that they were prescribed. The arrangements to support people with diabetes were not sufficiently clear which could lead to people not receiving the medication they needed.

Staff had access to regular training but they were not always putting what they learnt into practice. Supervisions were not taking place regularly and consequently good practice was not being imbedded.

People were positive about the food and we observed that the meals were nicely presented and nutritious. However the deployment of staff impacted on the serving of meals and the support available to people. There were systems in place to identify those at risk of poor nutrition and additional snacks were available.

People had access to a range of community health care support and we saw that appropriate referrals were made to health care professionals.

People gave us contradictory feedback about the service and the relationships that they had with staff. Some people were happy with the care but others were not and told us that staff were rushed and not able to provide the care they needed. We observed both good and poor practice. Some staff were kind and caring but others did not have regard for peoples dignity and did not give people the reassurance they needed.

There were care plans in place but there were omissions and they did not give sufficient direction to staff which meant that people were at risk of inconsistent care.

People had access to a range of activities to promote their wellbeing. People were positive about the opportunities provided to them to access the community.

There was a complaints procedure in place and we saw that people’s concerns were responded to in a formal way. However the process did not follow best practice and we have made a recommendation regarding this.

The manager was supported by a deputy manager and a clinical lead. Staff and people using the service told us that they would like the manager to be more visible. The provider had a range of systems in place to collect information on risks and a number of audits had been undertaken. These had identified some but not all of the issues that we had found a

The inspection took place on the 25 November 2015 and was unannounced. Barking Hall Nursing Home provides care and accommodation for up to 49 older people. There were 44 people living at the service on the day of our inspection.

The service has a registered manager. 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 spoke positively about the service and the approach of staff however they expressed concerns about staffing levels and how this impacted on their daily life. We found that staffing levels were not adequate and this meant that at times people had to wait unduly to receive support. The home was not fully staffed and permanent staff were being supported by agency staff, we were told that staff recruitment was underway to cover existing vacancies. The systems in place to recruit staff were thorough and provided protection to people. Staff had a good understanding of abuse and the steps that they should take to protect people.

Risks to individuals such as those associated with tissue viability and falls were identified but not always managed in a proactive way which took into account best practice. Management plans would benefit from greater detail and more analysis.

Induction training provided new staff with the guidance they needed and staff told us that they were well supported when they started work at the service. Training to further develop staff skills and knowledge was not however effective as it did not ensure that staff had to knowledge they needed to meet people’s ongoing health and support needs.

People were provided with a balanced diet but told us that they would like greater variety. The availability of staffing impacted on the serving of meals and meant that people had to wait to be served.

Care plans documented people’s needs but varied in quality which meant that some people were at risk of receiving inconsistent care.

Activities were regularly provided but did not always meet people’s needs and promote their wellbeing.

The manager was approachable and promoted an open culture. Staff knew what was expected of them and there were systems in place to drive improvement.

The service provided training in the form of an induction to new staff and comprehensive on-going training to existing staff. The senior staff in the service were knowledgeable with regard to Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The service had made referrals and worked with the Local authority to support people who used the service with regard to (MCA) and (DoLS).

You can see what action we told the provider to take at the back of the full version of the report.

We spoke with five people who used the service, looked at six care records and spoke with four members of staff. We viewed the staff rota’s and quality monitoring systems. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service the registered manager greeted us and noted our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

We saw the staff rota and dependency levels assessment which showed that the service assessed people's needs to ensure that there were sufficient numbers of staff to meet their needs.

We reviewed staffing records regarding The Mental Capacity Act (MCA) 2005 in relation to Deprivation of Liberty Safeguards (DoLS) and saw this training was up to date. The CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

There were systems in place to audit medication and care plans which ensured effective organisation in the delivery of care.

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were reviewed monthly and updated appropriately which meant that staff were provided with up to date information about how people's needs were to be met.

Is the service caring?

We saw that the staff interacted with people who lived in the service in a caring, respectful and professional manner. One person told us: “The dinners are lovely and staff always ask if you have had enough to eat.”

Is the service responsive?

The service had an effective complaints procedure in place. We examined six people who used the service care records and noted the that risk assessments were reviewed and updated in in response to events. This ensured people received safe and appropriate care.

Is the service well-led?

The service had been restructured since our last inspection which gave the manager identified and protected time to plan the service delivery. This also supported the manager to have the time to tour the service at least once per day to meet with people who used the service and staff to resolve issues at the time. The service worked well with other organisations and services such as health and social care professionals to make sure people received their care in a joined up way.

We spoke with seven people who used the service, the manager, six members of staff and two relatives as part of this inspection. People who used the service told us that they were pleased with the care they received. One person told us, "I never thought I would need a home but I am happy and the staff look after me well.” Three People told us the food was lovely and there was plenty of choice on the menu.

The equipment was regularly maintained and there were service level agreements in place for maintenance and repair. The service sought consent from people about how they wished for their care to be delivered. We did find some of the care plans had not been reviewed and updated with monthly information. The manager confirmed all supervision and appraisals had been completed. We reviewed the supervision and appraisals policy which stated supervision sessions should every two to three months. The manager was providing all the supervision and appraisal sessions themselves but not to this frequency. The provider had not followed their own policy and in relation to ensuring the service was well led. The provider had not fully supported the manager with regard to monitoring the quality of the service with regard to care plans.

We spoke with six staff who all reported they felt supported by the manager. One staff member said, "The manager comes around the service each day to check everything is alright." There was a training programme in place.

Our inspection of 11 May 2012 found that people were not being protected from the risks of unsafe or inappropriate care and treatment. This was because systems in place were not effectively assessing and monitoring people's nutritional and fluid intake. This did not ensure that people were receiving sufficient amounts of food and drink to maintain their health. We found that there was a lack of support from staff, where necessary, for the purposes of enabling people to eat and drink. We also identified that staff did not always treat people in a dignified way.

On this return visit we found that the provider had made the improvements required to achieve compliance with regulations for respecting and involving people who use services, meeting people’s nutritional needs and maintaining appropriate records. Our observations and discussions with people using the service and staff confirmed that the mealtime experiences of people using the service had improved.

We spoke with three staff who told us that there had been a lot of changes made to the service since our last visit. They told us that these changes had improved the atmosphere and morale for both the people using the service and the staff.

One relative spoken with praised the service and the staff. They commented, “I don’t have to worry about Mum, they are well looked after by the staff, who always make sure that they have plenty of fluids and a good diet”.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of an inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an “expert by experience” people who have experience of using services and who can provide that perspective and a professional advisor”.

During our visit to Barking Hall on 11 May 2012 people told us that they were happy with the service they received and that the staff were polite and treated them well. Some of the people we met living in the home were not always able to verbally communicate. Therefore we used our observational skills and relied on staff to speak on behalf of these people.

People had differing views on whether or not personal care was offered in a timely fashion. One person told us that they were “very satisfied” with all aspects of their care, however several people commented on the length of time it took for staff to answer call bells. For example, one person said that they, “Felt very embarrassed about accidents”, when they had to wait a long time for assistance to get to the lavatory.

People told us that they can choose where they want to eat their meals, and were offered sherry before lunch. People told us that they have a good choice of food and snacks including fruit, which was available on request.

Relatives told us that they were welcome to visit at any time of the day or night and were made to feel welcome by staff.

People told us that the service they received had improved since the last time we visited Barking Hall on 27 January 2011. The increase in staffing numbers meant that they no longer experienced a long wait before their call bells were answered and staff had more time to spend with people while supporting them.

People told us that they liked living in Barking Hall, that the food was good and the home was comfortable.

However, when we spoke to people living in the home, the main topics of conversation were the time it took to get help, to finish meals and the lack of staff. Two people told us that they had missed breakfast on occasion because it took so long to for staff to come and help them get up.

All of the people living in the home we spoke with praised staff for their kindness and their caring attitude. Some people said that they felt staff worked very hard but were let down by the providers because they did not make sure enough staff were on duty at the most busy times.