Barnet Grange Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive learning culture based on openness. Potential concerns about safety were not always investigated fully with actions taken. Lessons were not always learnt to continually identify and embed good practice.

Some incidents were not always investigated in a full and open manner to identify what happened and make improvements. For example, a person had fallen and experienced a head injury. Staff told us and records showed this person had triggered their call bell to summon staff help for 30 minutes, until staff responded and called an ambulance. The handling of the incident had not noted this delay in care, the failure of the call bell system and the actions taken to address these issues, to ensure this did not happen again. 1 member of staff felt this issue had not been addressed in an open way by management. The provider had also not taken prompt actions to improve the call bell system as there were still issues with this when we visited a month after this incident.

The provider made sure there was continuity of health care, including when people moved between different services. The provider also worked with people and healthcare partners to establish safe systems of care. However, these systems were not always followed by staff.

People saw a GP on a regular basis. A frequent ‘GP ward round’ was established and the nursing manager closely oversaw people’s health needs. However, we found there were 2 occasions when the staff involved had not promoted people’s interests and safety in relation to their health needs. For example, with 1 occasion of pain management when staff did not tell the GP about the changes in needs and high level of pain a person was in. There were also delays with a person receiving an important piece of equipment. Improvements were needed with how the management and provider monitored this aspect of people’s care to ensure people were always safe and they received support in a timely way.

The provider shared safeguarding concerns quickly and appropriately. But some staff and managers did not always support people to live safely, free from bullying and abuse.



During the assessment a person made allegations about a member of staff. We asked the provider to refer this to the local authority, which they did in a timely way. A number of people also reported to us they felt “told off” at times by a few members of staff, which made them feel vulnerable. One relative raised similar concerns to a manager, but later they told us they were subsequently “confronted” by the member of staff in question about this. Further work was needed to promote everyone’s safety and ensure staff and managers always followed appropriate safeguarding processes when concerns were raised.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some people had risk assessments in place to manage the risks which they faced. However, 2 people faced potential risks of being harmed or harming others which had not been identified and explored with a plan of action in place for staff and managers to minimise this type of risk. For example, 1 person who could express aggression to others did not have a risk assessment, review and care plan about this to support the management of this risk. The provider was aware of this risk and had taken some actions, but they had not checked to ensure the risk had been explored, documented and staff had a plan to follow, to promote everyone’s safety. We fed this back to the managers and suggested they acted on this.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care at all times.

Safety checks were in place, for example for fire safety and for the building. However, there were issues with safe water temperatures which were not acted on in a timely manner. People’s electric call bells were not always connecting to staff’s handheld devices, so staff could respond to a person requesting support. This was known to managers, but they had not taken timely action to try and resolve this in the short term. We also identified other safety issues, such as staff that had not kept dishwasher detergents and thickening agents secured as directed by managers. A ladder was also left in an open communal room in Copperfield. Even after we directed managers to the ladder it was not removed until we raised this a second time. These shortfalls had the potential to harm a person. Managers, staff and the provider were not always working collectively to promote a safe environment for the people who lived at the home.

The provider made sure there were skilled and experienced staff, who received effective support, supervision and development. But there were shortfalls in staffing levels at certain times of the day.

Some people reported to us they were encouraged to not use their call bell at night and in the morning by staff on duty. People gave examples of wanting support at these times to have a hot drink or breakfast in the bedrooms, or to be supported to walk. Staff told us they struggled to manage these needs in the mornings and evenings alongside the need of people wanting to use the bathroom or to have a wash. Some staff also felt the deployment of staff at these times needed to be reviewed by the provider. Other people were sympathetic of staff during these times and said they did not like to “Make a fuss,” so they compromised their wishes which included not asking for assistance to have a shower. During the day we saw there was enough staff to support people, but further work was needed by the managers to effectively assess and manage staffing levels. For example, during busy periods in the mornings and evenings to ensure people consistently received timely care which met their needs. Care staff spoke well of the support from their direct supervisors and managers. They were satisfied with the level of training provided, supervisions, and team meetings. Staff were safely recruited by the provider.

The provider and managers did not always assess and manage the risk of infection.

The home was clean, and staff spoke well of the availability of personal protective equipment. However, we identified 2 shortfalls during our first visit to the home which had the potential for infections to spread. We found a person’s ensuite was unclean after the room had been cleaned and the person had not returned to it. We later found the ensuite was still unclean. We asked the manager to address this for this person. Staff were also sharing the 1 available piece of equipment for the last week to help people move in the home as the other 2 pieces of equipment were being fixed. Staff did not routinely clean this one piece of equipment when they used it to support people to move about the home, even though this was being used frequently between the two different parts of the home.

The provider did not always make sure medicines and treatments were safe and met people’s needs. Staff did not always involve people in the planning of how their medicines will be administered.

People did receive their medicines as prescribed at the time of the assessment, but there had been recording errors made previously which were a repeat of the errors made previously, so effective learning from these incidents had not been established. Nor was there an action plan in place when these errors were identified. Guidance for staff was inconsistent to support people who had prescribed creams and ‘as required’ medicines. Best practice processes had not been followed when some people needed covert medicines.