North Bay House

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Inadequate

• Caring

  Inadequate

• Responsive

  Requires improvement

• Well-led

  Inadequate

Our view of the service

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.

People's experience of this service

During the assessment, we received feedback from 6 people who used the service and 2 relatives. We spent time observing people and staff. People’s views on feeling safe with care staff were mixed; some people felt well looked after, while others noted that the skills and experience of staff varied, with reference to new staff and the need for better training. One person told us, “The building, the fabric is okay, but the carers and the management I’m not sure of at all.” Another said, “Some staff are good and some are not. I think this comes down to training.” One person raised concerns about a staff member whose tone they described as ‘curt and dismissive’ when responding to call bells. Another mentioned occasional sharpness from staff when discussing fluid intake. There were specific concerns from 1 person regarding communication and staff attitudes when they questioned their treatment. Relatives and visitors felt happy with the care provided. One relative told us, “They’re so good here, I felt a huge pressure being lifted when [relative] came in here. They monitor their fluid intake which I think keeps [relative] safe with hydration too.” A visitor told us, “Oh very [safe], yes. [Friend’s name] is very happy here.”

Some people had concerns about under staffing and its impact on response times when they needed assistance. One person said, “The staff are run-ragged. They do stop and chat now and then, but they’re always wanted elsewhere.” Another said, “I think they’re 10% short and something needs to be done. We can wait as much as 15 minutes at night.” Some people felt fully informed and in control of their care, whilst others were less aware of formal care plans.

We observed people sat in various areas of the home for long periods, with no activity being offered. Staff interactions were observed as kind and caring, however, we also saw that staff often walked through communal rooms with no interaction with people. Records we reviewed showed that minimal activity was happening in the home on a day to day basis. One person said, “I will just sit here and be bored for hours and hours.”

Views on leadership and management were mixed. Some people felt the home was well managed, describing positive experiences with the registered manager and how staff worked well together as a team. However, others were less certain, with 1 person explicitly stating that leadership needed improvement and another finding it difficult to judge.