This unannounced inspection took place on Thursday 01 June 2017.

Barley Brook is registered to provide accommodation and personal care for up to 28 people who are living with dementia. The home is situated close to Wigan town centre and close to local amenities and public transport routes.

We last inspected Barley Brook in December 2015. The home was rated as ‘Requires Improvement’ overall and for the ‘Key questions’, ‘Safe’ and ‘Responsive’. The remaining key questions were rated as Good. We found two breaches of the regulations with regards to safe care and treatment and person centred care. At this inspection, we checked to see if sufficient improvements had been made.

People living at the home told us they felt safe. The visiting friends and relatives we spoke with also felt Barley Brook was a safe environment for their loved ones to live.

We looked at how the home protected people from abuse and improper treatment and reviewed the safeguarding procedures that were in place. Records showed safeguarding referrals were routinely being made appropriately. However, we became aware of one incident that hadn’t been reported to safeguarding. This was addressed immediately during the inspection. We have made a recommendation about this in the detailed findings of the ‘Safe’section of this report.

We found certain staff had a limited understanding of DoLS (Deprivation of Liberty Safeguards) and the MCA (Mental Capacity Act), with limited training undertaken. We raised these concerns with the registered manager who arranged for DoLS and MCA training to be delivered to all staff in July 2017.

We found medication was ordered, stored and administered to people safely. There were audits of medicines to ensure shortfalls in practice would be identified and actioned. There had been problems with the medication fridge as the temperature had been out of range on certain days, however the registered manager had arranged for it to be replaced and we saw the replacement fridge was delivered on the day of the inspection.

Staff were recruited safely with references from previous employers sought and DBS (Disclosure Barring Service) checks undertaken. This would ensure that staff employed were suitable to work with vulnerable adults in a care setting.

There were sufficient staff working at the home to meet people’s needs, with a dependency tool used to determine how many care hours were needed to safely meet the needs of people living at the home. Feedback from people living at the home, visitors and staff was that staffing levels were sufficient and we observed staff attending to people’s needs in a timely manner during the inspection.

Staff received an induction when they started working at the home and received appropriate training, supervision and appraisal to support them in their role. MCA/DoLS training was an area of training which staff needed to complete, however the manager had already arranged for this to be undertaken by staff.

The home worked within the requirements of the MCA (Mental Capacity Act) and DoLS (Deprivation of Liberty Safeguards). We saw appropriate assessments had been completed if there were concerns about a person’s capacity. DoLS referrals had been made as necessary to the local authority. The registered manager maintained accurate records of DoLS applications in the office which was updated as necessary. All relevant documentation relating to these decisions was held in care plans.

We saw people received enough to eat and drink, with people making positive comments about the food provided at the home. The staff we spoke with knew the people who were at risk with regards to their nutrition such as if they had lost weight or needed support to eat and drink. The information was also passed on to staff in the kitchen to ensure they were aware of the people who may be nutritionally compromised.

The people we spoke with and their visiting relatives made positive comments about the care they received. People

This unannounced inspection took place on 08 December 2015.

Barley Brook is in Wigan and is owned by Rosewood Healthcare. The home is registered with the Care Quality Commission (CQC) to provide care for up to 28 people. The home provides care to people with residential care needs, many of whom are living with a diagnosis of dementia. We last visited the home on 06 February 2015 where the home was rated as ‘Requires Improvement’ overall and in each of the five, key questions, with three breaches of regulation. This inspection looked at any improvements made since then.

During this inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to Person Centred Care and Safe Care and Treatment.

People living at the home told us they felt safe, as did relatives that we spoke with. Staff also displayed a good understanding of Safeguarding and how they would report any concerns. This helped to keep people safe.

At our previous inspection we had concerns about how medication was handled. Although we saw improvements in this area since the last inspection, we still identified problems with how medicines were given to people who lived at the home. These issues related to wastage of medication, care plans not being updated where dosages had altered, lack of recording where medication had not been given and in one instance, where a person’s medication had not been changed from tablet to liquid format, due to swallowing problems.

We looked at maintenance records held by the home to ensure that the building was safe for people who lived there. With regards to electrical maintenance, it stated that ‘Urgent/Immediate’ work needed to be carried out, although we saw no evidence that this work had been undertaken.

We found that staff recruitment was safe overall, although where one member of staff had previous criminal convictions on their DBS form, we were unable to see that an appropriate risk assessment had been undertaken. This would ensure that it was still suitable for them to work with vulnerable adults.

The home used a dependency tool to identify how many staff were required to safely meet the needs of people who lived at the home. Overall we found there were sufficient staff working at the home on the day of the inspection. This included the home manager, deputy manager, a senior carer and two care assistants. The night shift was staffed by a senior carer, who was able to give people medication during the night and two care assistants. This was to provide care to 25 people.

The home used a matrix to monitor the training requirements of staff. This showed us that staff were trained in core subjects such as safeguarding, moving and handling, infection control and health and safety. Each member of staff we spoke with told us they were happy with the training and support available to them. Staff also had access to an induction programme when they started working at the home and received regular supervision. Staff supervision was one of the areas where we found improvements since the last inspection.

We observed the lunch time meal served at the home. We saw staff displayed a good understanding of people’s nutritional needs and offered choice where necessary. Some people required a ‘soft’ diet and we saw this was provided for them in order for them to consume their food safely.

Overall, the people we spoke with told us they were happy with the care they received at the home, although many were unable to fully communicate their views to us. Relatives told us they didn’t have any concerns and reported seeing vast improvements at the home over the past 12 months.

We saw that people were treated with dignity and respect and were allowed to retain their independence where possible. Staff were also able to provide good examples of how they did this when delivering care.

Each person living at the home had their own care plan, which provided an overview of the care and support they needed to receive from staff. During the inspection, we identified several instances where guidance in care plans was not followed by staff. Additionally, care plans didn’t always provide an accurate picture of what peoples care requirements were. One person who didn’t communicate verbally, had limited information in their care plan about what their body language meant to staff. This meant staff couldn’t always be responsive to people’s needs.

We found that complaints were responded to appropriately, with a policy and procedure in place for people to follow when they needed it. Additionally, we saw that a response had been provided to the complainant, letting them know of any action that had been taken.

The staff we spoke with were positive about the leadership of the home and told us they had seen great improvements at the home in recent months.

At the time of our inspection, the home manager was not yet registered with the Care Quality Commission, although they had attempted to register on several occasions. 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 various systems in place to monitor the quality of service provided to people living at the home. These included the use of regular audits and seeking feedback from people who lived at the home through surveys and using the feedback to improve the quality of service.

Barley Brook is a care home in Wigan and is owned by Rosewood Healthcare. The home is registered with the Care Quality Commission (CQC) to provide care for up to 28 people. The home provides care to those with residential care needs, although a large number of people live with dementia.

We last visited the home on the 07 and 09 of July 2014 during the testing phase of the new inspection methodology. The service was rated as ‘Inadequate’ during this inspection and we issued seven compliance actions with regards to care and welfare, safeguarding, medication, suitability of the premises, records, supporting workers effectively and monitoring the quality of service. We also issued a warning notice for regulation 10 with regards to monitoring the quality of service effectively.

At the time of our inspection, the manager was new in post and as such, was not yet registered with the Care Quality Commission. 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 the registered person had not protected people from the risks associated with monitoring the quality of service, medication and record keeping. These were breaches of regulations 10,13 and 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These relate to regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment and governance.

At our last inspection we had concerns about how medication was handled in relation to hospital discharge and covert medication. During this inspection we had further concerns with regards to how people’s medicines were handled. We found unsafe processes around the administration of medicines from the Bio dose system whereby medication could not easily be identified by staff. For example where specific administration instructions were required. This put people at risk of errors in selecting the wrong medication and also not receiving the medication in a safe manner.

We found improvements were required to handwritten medication records (MAR) to ensure staff were aware of any specific warnings relating to a certain medication so that administration was safe. We found one example where a person was put at risk with their medicines as the member of staff did not know this information.

We found examples of medication being given without due regard to any specific warnings. This put people at risk of the medication either not working in the best way or at risk of experiencing side effects. One person had run out of medication and not received a dose of the medicine as needed in the morning. This identified poor management and ordering of repeat medication, which put this person at risk with a delay in receiving the medicine. It was a particular concern that some people were given medicines late in the morning, as they were sleeping when staff first attempted to administer. However, no advice had been sought to ensure safe administration.

There was no consistent information available regarding PRN (when required) medication to support staff to administer medicines safely. Due to the lack of supporting information, it was unclear whether people received these medicines at the time they needed them. It was of particular concern for those people who could not clearly communicate their needs, as there was no evidence that their needs had been observed. The manager informed us that she was in the process of drawing up pain relief treatment plans which would help to address this concern.

At our last inspection we had concerns with regards to the safety of the premises and the fact that people had been able to access areas of the home which could place them at risk. We saw improvements in this area, as the home had introduced ‘key pad’ locks to areas of the home including the cellar, staircase and court yard at the rear of the building, which prevented potential trip hazards to people. One person had been able to leave the building due to a window only being secured with a chain as opposed to a window restrictor. During the inspection we found windows had now been fitted with suitable window restrictors, which prevented people leaving the building in a potentially unsafe manner. There were also specific risk assessments in place to cover these areas with daily, weekly and monthly checks in place.

At our last inspection we found appropriate Deprivation of Liberty Safeguards (DoLS) applications had not been submitted to the local authority when people had attempted to leave the building. The manager now kept a checklist in the office to show which people came under a DoLS and if an application had been made. In addition, people had specific DoLS care plans in place where necessary.

At our last inspection we had concerns about night time staffing levels and the fact that with no senior member of staff available, there was nobody to give medication to people such as pain relief. During the inspection we looked at staff rotas and saw senior care staff had been added to the night time rota and were supported by two care assistants. We were able to see these staff were on shift when we first arrived at the home in the morning.

We looked at how staff were recruited and looked at six staff personnel files. Overall, we found suitable checks were undertaken before staff began work, including ensuring two references were sought and DBS checks undertaken. However, we found one member of staff had only personal references on their file and none from previous employers, despite having been employed elsewhere previously. We raised this with the manager who told us this member of staff had started working at the home before she had commenced the role as home manager, but would ensure appropriate checks were made in the future.

Staff supervision at the home was not consistent. Of the six files we looked at, only two had received supervision despite having worked at the home for several months. We raised this with the manager to see if the records were located elsewhere, however we were not shown them. Following our inspection, the manager sent us a supervision matrix which showed the majority of staff had received supervision in late February 2014 and would receive further ones every three months.

At our last inspection we felt the layout of the home was not suitable for those living with dementia. During this inspection we undertook a tour of the building to see what improvements had been made. Toilets, the lounge area, bathrooms, the dining room and ground floor were all clearly sign posted and supported by pictures, for people who may have difficulty with cognition. The sample of bedrooms we looked at had a large picture of the person living there and the number of their room was clearly displayed. The colour of people’s doors was very similar to the colour of the walls, which could present difficulties for people in successfully finding their bedroom. We raised this with the manager who told us plans were in place to ensure doors clearly stood out from the rest of the home decoration and were easier for people to find.

At our last inspection we observed that there were a number of missed opportunities for interaction, between staff and people living at the home. During this inspection we saw that on occasions, this still presented an issue. We spent time observing care in the main lounge area of the home during the morning of the inspection. At this time, there were six people seated in the lounge area and on several occasions, staff walked straight through the lounge area from the kitchen area without acknowledging people or asking if there was anything they needed. We raised this issue with the manager who said she would re-iterate this to staff.

During our inspection we observed two people who struggled to communicate verbally, both with staff and other people living at the home. Their speech was unclear and it was difficult to understand what they were saying. We found there were no specific communication care plans in place to demonstrate what staff needed to look for to understand their requirements and what potential body language to look out for. We raised this with the manager who told us they would ensure these care plans were in place following our inspection.

At our previous inspection we identified concerns with the homes record keeping. Whilst looking at people’s care plans we became aware that certain people needed to be weighed weekly, although records in care plans did not support that this had taken place. Additionally, we found three people required to be re-positioned at regular intervals and again, records did not support that this had taken place in line with the necessary timescales. We raised this with the manager who was confident these tasks had been completed by staff, but that accurate records had not been maintained.

At our previous inspection, we felt people’s care plans could have been more person centred, capturing things of importance to them such as likes, dislikes and their life histories. In response to this, the manager told is they had introduced ‘This is me’ documents for each person living at the home. This detailed people’s life story, photos of when they were younger, where they were born, hobbies/interests and war time experiences.

We saw a system had been introduced called ‘You said, we did’. This was a survey sent to staff, people who lived at the home and relatives asking how they would like things to be improved within the home. This asked questions about laundry services, food/menus and the general cleanliness of the home.

There were a range of audits undertaken at the home. These covered pressure sores, bed rails, medication, infection control and falls. Additionally, there were regular checks of window restrictors, fire exits, the courtyard door, building maintenances, step ladders and wheel chairs. Despite these audits being in place, there were no systems in place to check other important aspects of the service such as weekly/monthly weights, people being re-positioned and staff supervisions were being completed when they should. Additionally, the medication audits in place did not highlight the shortfalls we had identified.

We visited this service because there had been some concerns about the way medicines were managed in December 2012. We found that improvements have been made in the safe handling of medicines in February 2013. At this visit we wanted to make sure those improvements had been maintained and people were still protected against the risks associated with the safe handling of medicines.

We spoke to one person about the way staff handled their medicines. They told us they were very happy with the way they were given medication and that the staff knew what the medicines were for. We observed how they people were given their medication. We also looked at records about their medication and the medicines in the home for them.

When we visited in March 2013 we found the service to be non compliant in several areas. The purpose of this visit was for us to see what improvements had been made by the provider.

During this visit we saw that improvements had been made in all of the identified areas and that a new manager and area manager were in post. The manager was planning to make a formal application to the Care Quality Commission to become registered.

We saw that people were being supported by staff at mealtimes in an appropriate way and that the food appeared appetising and was plentiful. One person living at the home told us that '' the meals are very good''. A relative told us that '' the home has improved greatly''. They also told us that the staff were managing their relatives condition very well but that some stimulating activities were needed.

One person living at the service told us that there was ''always someone to help''.

We discussed staffing levels with the manager and the area manger as there were two members of staff on night duty to provide care to people over the three floors of the building. They told us that at this time this was adequate to meet the needs of the people who were living there and the manager was also available on call if needed. However, they also told us that they would discuss this with the provider.

We observed the staff to be interacting well with each other and the people living at the home who they treated with dignity and respect.

When we visited in November 2012 we found the service to be non compliant in several areas. The purpose of this visit was for us to see what improvements had been made by the provider.

During this visit we saw that improvements had been made in how the service helps ensure that people's privacy, dignity and independence are maintained.

We found that improvements needed to be made to the environment, maintaining appropriate records and training for the staff team.

We spoke with several people who live in the home during our visit. Due to varying degrees of dementia most people could not express their experiences of the home. However nobody raised any direct concerns about the way their medicines were managed.

Overall we found improvements had been made and people were given their medicines safely.

We issued three warning notices to the provider in December 2012. The notices were served as the provider had failed to protect people from the risks associated with unsafe or unsuitable premises; failed to protect people against the risks of inappropriate or unsafe care by means of not having effective systems in place to assess and monitor the quality of the service and had failed to have suitable arrangements to ensure that people were safeguarded against the risk of abuse.

During this visit we saw that improvements had been made to the safety of people's living environment. Systems had been put in place for identifying the possibility of abuse and prevent it from happening and systems had been introduced to assess and monitor the quality of the service that people living at Barley Brook received.

We observed part of the lunchtime medicines round and saw medicines were administered to people in the main living areas of the home. Due to varying degrees of dementia we found it difficult to obtain the direct views of people who live in the home.

Overall we found medicines were not safely handled and improvements are needed.

At the time of the inspection the service was without a manager. The nominated individual for the service, who is the area manager, was in charge of the day to day management of the home.

The provider has engaged a care consultant to assist with the service moving forward and they were present for part of the day.

We found during the inspection that the refurbishment plan is ongoing and that the relatives and staff that we spoke with were positive of the changes that had been and were due to be implemented. This included environmental and management / support of staff and improvement of care for the service users.

One relative told us that the standards of care had started to improve following a recent increase in staffing levels.

A relatives meeting had been held and further ones were planned, although one relative told us that they had not received any information regarding the service in writing or in the form of a booklet. Any issues that they had they had raised with the manager and or the area manager had now been resolved.

One member of staff told us that they felt part of the changes and were now more involved and felt that issues would now be dealt with.

The purpose of this visit was to assess the improvements made with the service following our last visit.

No comments were received from the people living at Barley Brook in relation to the outcome areas we assessed during our visit. People we saw and spoke to during our visit appeared happy and content.

The people living at Barley Brook have varying stages of dementia and because of this people were unable to make comments on the care and treatment they received. This report is based on our observations of people living at Barley Brook and our discussions with their relatives.

People told us :

" We did have a few concerns about the care at night, we were able to resolve this but it did take some time".

" The staff work hard, I have nothing but praise for the staff."

"The food here is very good. My Mother eats everything."

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

Barley Brook provides accommodation, care and support for up to 28 people who have a primary diagnosis of dementia. At the time of the inspection, 23 people were living in the home. The home is situated close to the town centre of Wigan. The home was arranged over three floors with lift access between floors.

A registered manager was in place at Barley Brook.  A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

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

People had been put at risk because appropriate steps had not been taken to identify, assess and manage all the risks relating to the welfare and safety of people using the service. We found a number of environmental risks within the building, which had not been minimised. This made the service unsafe. In addition, the layout and design of the building was not ideal for people living with a diagnosis of dementia.

An application for a Deprivation of Liberty Safeguards (DoLS) authorisation that should have been made had not taken place. This meant the person could be subject to a breach of their human rights. We also found medication was managed unsafely and inappropriately for one person on their return from hospital.

Staff that had been employed by the service for longer than six months had received training in key areas. However, staff that had started more recently had only received a basic induction and moving and handling training whilst employed by the service. This meant they may not have the skills required to deliver care and support effectively. Staff were supported through supervision, however the appraisal system had lapsed.

Care records identified people’s care and support needs and we saw evidence people’s care was regularly reviewed. However, people’s care records lacked detail about their personal preferences and social histories. Accurate records had not been maintained for each person who used the service.

People’s nutritional and hydration needs were being met. In addition, there was evidence of people being visited by a range of healthcare professionals, which demonstrated people’s healthcare needs were being met.

Staff were caring and treated with people with dignity and respect. Efforts were made in the majority of cases to support people to remain independent. We observed positive interactions between staff and people who used the service but there were missed opportunities for staff to initiate communication and engage people in conversation.

People and their relatives had opportunities to raise their views and experiences about Barley Brook. There was a complaints system place and people told us they would feel confident raising any concerns with the registered manager or other staff.