The Care Quality Commission
  • Care Home
  • Care home

North Bay House

Overall: Requires improvement read more about inspection ratings

Borrow Road, Lowestoft, Suffolk, NR32 3PW (01502) 512489

Provided and run by:
Hellendoorn Healthcare Limited

All Inspections

During an assessment under our new approach

Date of inspection: 14 and 21 May 2026. This inspection was carried out to follow up on previous breaches of regulation. The service is a residential home for up to 29 people. At the time of the inspection there were 20 people living at the home, some of whom were living with dementia.

The provider was previously in breach of the legal regulations in relation to safe care and treatment, staffing, consent procedures, safeguarding, failure to notify reportable incidents, governance and person-centred care. Improvements were found at this inspection, and the provider only remained in breach of 2 legal regulations relating to person-centred care and governance of the service.

The provider had begun to implement changes, including the introduction of new leadership and the development of plans aimed at driving improvement. They demonstrated some improvements in maintaining a safer culture, supported by care planning, and partnership working.

There were systems in place to assess risks to people and ways to reduce them, but these did not always include all risks affecting people to ensure risk mitigation was in place, and guidance for staff was readily available. The quality of risk assessments varied, with some risks being very well detailed whilst others were not. Records were not always accurate and/or complete. This was important as there were new staff working at the service who required accurate guidance to enable them to provide care which was effective and safe.

Oversight of risk relating to people’s skin conditions or injuries such as bruising was improved, but systems in place were not being used effectively to enable the service to monitor healing or indicate how the injuries had been sustained.

Infection prevention and control systems were in place, but these had not always identified issues we found such as rusted equipment which could not be cleaned effectively. We also identified an unsafe piece of toileting equipment which could have caused injury if this had been used by a person. Audits therefore needed to be more robust to capture concerns more effectively.

Records confirmed that people received their medicines as prescribed, however, we noted some gaps in the medication administration records including some related to the day of the site visit. Written guidance for staff about some medicines prescribed for occasional use was not always available. Information that was available for laxative medicines prescribed ‘as required’ lacked information for staff about the maximum period of use for these medicines.

Staff received training relevant to their role, however some additional checks were needed to ensure staff had understood the training they received and implemented this into their day-to-day practice.

Staffing levels were safe, and staff told us they gave people choice and helped them maintain their independence. However, we observed that in practice not all staff delivered care in line with the Mental Capacity Act 2005 (MCA), such as gaining consent prior to assisting people to move. MCA records were more detailed and completed prior to restrictions being implemented to ensure they were the least restrictive option.

Care plans contained more person centred detail, however, there was limited reference to future planning, or consideration of goals or aspirations of each person.

People were supported to take part in activities in the home and community.Activity co-ordinators we spoke with understood the importance of tailored activities to enhance person centred care and had implemented a ‘wish tree’ for people to use.

Staff knew people well and understood their needs and preferences. Most family members told us they were very happy with the service delivery, the provider, and the management team. People had choice over personalising their rooms, and family and friends could visit at any time without prior notice.

There were auditing systems in place, including provider audits. However, audits had not always been sufficiently robust to identify some of the issues we found. During and following the inspection, the registered manager and regional manager took action to begin rectifying areas which required improvement. Action plans were in place and progress was being made.

This service has been in Special Measures since 31 October 2025. The provider demonstrated improvements that have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

We asked the provider for an action plan in response to the concerns found at this assessment.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

During an assessment under our new approach

Date of Assessment: 04 and 14 August 2025. This assessment was prompted in part due to concerns raised around the quality of care people received, staffing and governance. The service was last inspected 11 October 2018 (published 6 November 2018). The service is a residential care home for up to 29 older people. At the time of assessment there were 27 older people living at the home, some of whom were living with dementia.

We identified 7 breaches of regulation relating to receiving safe care and treatment, staffing, consent procedures, safeguarding, failure to notify reportable incidents, person-centred care, and governance of the service. The provider did not have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice. Governance processes required significant improvement as audits had not identified the serious concerns we found. Environmental risks had not been identified or acted on to reduce risk to people living in the home. The service did not always make sure that medicines and treatments were safe and met people’s needs. Documentation around consent procedures did not reflect that the least restrictive measures were in place, and that people were given as much opportunity as possible to participate in their care and make choices. Safeguarding concerns were referred to the local authority safeguarding team, however, actions to ensure people were kept safe were not taken promptly, resulting in people not always feeling safe and some experiencing harm. Internal reviews into safeguarding concerns were not completed by the service to ensure people were kept safe. Notifiable safety incidents were not reported to CQC. Staffing levels were not sufficient to ensure that communal areas were observed to ensure people’s safety. Staff did not have all the training they needed to ensure people were cared for safely. Care plans and risk assessments lacked person-centred information to enable care staff to provide effective and safe care to people.

Due to the serious concerns found during the inspection, we imposed urgent conditions on the providers registration. This included a restriction on admissions to North Bay House, and a requirement for the provider to report to us weekly in respect of any incidents that occur and how risk is being mitigated. We have also asked the provider for an action plan in response to some of the concerns found at this assessment. This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

2 February 2021

During an inspection looking at part of the service

North Bay house is registered to provide care and support to a maximum of 29 people, some of who may be living with dementia.

We found the following examples of good practice.

The service was only receiving essential visitors at the time of our inspection. Any person entering the building had their temperature taken, completed a health questionnaire and wore full personal protective equipment (PPE) including a face visor. Where visitors were unable to visit in person, staff had set up different ways in which people could stay in touch with those who are important to them. This included by phone and tablet. People experiencing dementia were supported by staff to engage with these virtual opportunities. Staff recognised that people missed contact with their friends and relatives and had continued to deliver a full programme of activities to cheer people's mood.

The building was clean and free from clutter. The housekeeper told us that the cleaning schedule was updated at the beginning of the COVID-19 pandemic. This now included regular touch point cleaning, where all regularly touched areas, such as light switches and door handles, were disinfected. Oversight of laundry was comprehensive and housekeeping staff demonstrated a good knowledge of the guidelines in place for washing people’s clothing should someone test positive for COVID-19.

A room had been designated to store all items coming into the service for 72 hours to prevent the spread of any infection entering the service. This included post and gifts delivered from relatives. All items were clearly marked with the date and time that they entered the room.

All staff undertook regular COVID-19 testing in order to protect the people they care for. Where staff test positive, they are supported to isolate at home and the appropriate authorities informed. Staff we spoke with were clear that the management team were supportive of their needs. Risk assessments for all staff had been undertaken and staff who needed to shield were supported to do so in an appropriate way. Handovers and staff breaks had been modified to ensure that only small groups gathered at any one time. If staff did meet in one room, they remained socially distant and wore PPE.

11 October 2018

During a routine inspection

North Bay House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. North Bay House is registered to provide personal and nursing care to a maximum of 29 older people. At the time of inspection there were 26 people using the service.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good. There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

The service continued to protect people from the risk of abuse or avoidable harm. Staff knew how to identify and report potential abuse and risks to people were identified and planned for. Medicines were managed and administered safely. The premises remained clean and there were processes in place to reduce the risk of the spread of infection.

The service continued to deploy enough staff to meet people’s needs in a timely way and to practice safe recruitment procedures.

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 continued to support this practice. Staff understood and promoted independent decision making.

The service provided people with a choice of adequate food and drink. Support people required to maintain good nutrition and hydration was reflected in care planning. People were supported to have contact with other health professionals where appropriate.

People received care from staff who had the training, skills and experience for the role. The service continued to offer staff extra training sessions so they could offer people enhanced levels of support.

People told us staff were kind to them and the service continued to promote a culture of kindness, with the registered manager, provider and all staff leading this practice.

The service continued to offer people personalised care based on their individual preferences and to involve people and their representatives in the planning of care. Peoples’ wishes were adequately reflected in care planning, including their wishes when coming to the end of their life.

People were provided with adequate sources of meaningful engagement and were supported to feedback their views and experiences through meetings and surveys. People were made aware of how they could complain.

The registered manager and provider continued to operate an effective system to monitor the quality of the service provided to people. Areas for improvement were identified and acted upon. Staff, people using the service and their relatives were enabled and empowered to be involved in the ongoing development of the service. Changes were made based on suggestions from people using the service, their relatives and staff.

Further information is in the detailed findings below.

25 January 2016

During a routine inspection

North Bay House is a care home providing care and support to a maximum of 29 older people. At the time of our visit there were 27 people using the service.

The inspection was unannounced and took place on 25 January 2016.

The service had in place 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 and their representatives told us they felt the service was safe. There were clear plans in place to reduce the risks of people coming to harm. Staff, the registered manager and the provider understood their role in keeping people safe.

People told us and our observations confirmed that there were enough suitably qualified, trained and supported staff to meet people’s needs. We observed that staff were competent in providing safe and effective care to people. Staff told us they received the training they needed to carry out their role effectively, and that they were supported to do their job.

There was a robust recruitment procedure in place to ensure that prospective staff members had the skills, qualifications and background to support people.

Medicines were stored and administered safely. There was a system in place capable of identifying errors. Plans were in place to improve medicines administration paperwork.

The service had made the appropriate Deprivation of Liberty Safeguards (DoLS) referrals for people using the service and was complying with the principles of the Mental Capacity Act 2005 (MCA).

People were supported to remain independent, and live full and active lives. People were supported to engage in meaningful activity by staff who understood the importance of this.

We observed, and people told us, that the staff were caring, kind and treated them with respect.

People told us they were involved in the planning of their care. However, improvements were required to ensure that people’s views on their care were reflected in their care records and that their records were personalised to them as an individual.

We observed that people were supported to eat and drink sufficient amounts.

There was a robust quality assurance system in place which we saw was capable of identifying shortfalls in the service so these could be addressed.

There was a complaints procedure in place and people knew how to complain if they were unhappy. People and their representatives were supported to feed back their views on the service and these were acted on by the manager.

Further consultation was required to ensure that the decision to have CCTV in place in some parts of the service was appropriately discussed with people using the service and their representatives to promote openness and transparency.

24 September 2013

During a routine inspection

During our inspection we spoke with five of the 26 people who were using the service at that time. We also spoke with three relatives who were visiting a family member at the time of our inspection and two members of staff as well as the provider and the registered manager.

People told us that the care and support they received was very good. One person told us that the staff, "Do everything that I want them to do, they are all so kind and helpful." Another person we spoke with told us that they enjoyed the food. They told us that, "There is always a choice if I don't like the set meal." They also told us that staff helped them with their medication. We were told that the service identified people's routines for example one person told us that they, "Always have a cup of tea first thing in the morning before they got up, something they had always been used to."

We looked at the care records of four people who used the service. These contained details about the needs of people who used the service and how those needs could be safely met. The records also detailed the health needs of the person and showed where professional medical support was needed.

The staff team operated a flexible shift pattern which meant that at the busier times of the day there were more staff available to help people. One person we spoke with told us staff always came quickly if they used the call bell.

25 October 2012

During a themed inspection looking at Dignity and Nutrition

We spoke with people who told us what it was like to live at this home. They 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 a themed 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 and an "expert by experience" (people who have experience of using services and who can provide that perspective).

We spoke with five people who were using the service and two visitors. Everyone we spoke with confirmed that the staff treated them with respect and provided them with choices wherever possible. People spoken with were complimentary about the care and attention that they received.

One person told us, 'Staff are very good, I enjoy a laugh and a joke with them and they always treat me with respect'. Another person told us that, "I am very happy here" and they went onto say that, "The staff always have time for us". A visitor told us that, 'My friend gets very good care, the staff are very good with them, they know their likes and dislikes and always observe their dignity. They are always friendly and have a laugh and a joke with them. Their room is very nice and the food is good'.

A visitor told us that, 'Staff are absolutely brilliant, they always make me feel welcome and they are very attentive to my friend'. Another person told us that, "There is a good mix of young and older carers with the young benefiting from the older carers' wisdom".

One person commented that, "We have a varied choice of food with plenty of fresh vegetables and it's always hot when served. They confirmed that hot and cold drinks were readily available in between meals and overnight. Everyone told us that finger foods were available between meals and overnight if required.

None of the people that we spoke with had any concerns about their safety in the service and were confident that the manager would resolve any concerns they might have.

For example, one person told us that, 'Staff are very good, I don't have anything to worry about' and added, 'I feel very safe here'. Another person commented, 'if I had any concerns I would speak to the manager and I know it would be resolved very quickly, they (staff) make me feel safe'.

Everyone that we spoke with assured us that the care they received was unhurried and that they were involved in making choices about the care they received. Everyone that we spoke with told us that they knew their care records are kept in the office and that they had regular discussions with staff about the care that they were receiving.

7 December 2010

During a routine inspection

We spoke with six people who lived at the home. They told us that their needs were met, that they were consulted with about the care that they were provided with and that they were provided with the opportunity to participate in activities that were of interest to them. They told us that the staff always treated them with respect and that their privacy was respected. People were complimentary about the home's environment, the staff that worked at the home and the quality of the food that they were provided with.