North Bay House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to consent to care and treatment.

This service scored 29 (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 make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. We observed a lack of assessment of people’s needs and risks to them. People’s needs assessments did not focus on people’s strengths. Care plans were not always detailed with a lack of information to reflect changes in people’s needs such as people’s mobility or specific health conditions resulting in gaps in the information available to staff. Some people with specific medical conditions such as diabetes did not have a care plan in place. This meant staff did not have guidance to effectively deliver people’s care safely.

The provider did not plan and deliver people’s care and treatment with them, including what was important and mattered to them.People were not always told about current good practice that was relevant to their care, nor were they meaningfully involved in how this was reflected in their care plans. We asked people if they were aware of having a care plan. One person said, “A care plan? not really, no.” Another said, “Not a care plan as such, no.”

Some staff were not confident when preparing fluids for people which needed to be thickened to reduce the risk of choking. For example, we observed staff adding too much thickener to a person’s drink which resulted in a jelly like consistency which would not be palatable or safe to consume.

Nationally recognised tools were used to assess and monitor people’s needs. However, Waterlow scores (a risk assessment tool to identify individuals at risk of developing pressure ulcers) were not always completed correctly which posed a risk to people as it was not always clear if people were at high or low risk of skin breakdown. Different area of people’s care plan contained contradictory information, which meant that guidance for staff on how to deliver people’s care was not accurate. Reviews were not always undertaken as frequently as required where people were at risk.

Some people were living with dementia; however, the care environment was not always dementia friendly. The provider had not researched evidence based practice to ensure the environment and care practices met people’s needs and enhanced their independence.

The provider did not always work well across teams and services to support people. The provider was not always proactive in working with other services when multidisciplinary involvement was required, and there had sometimes been a delay in referring people to external professionals when needed. People had mixed views about their care, one person said, “I have been to [2 hospitals] for reviews of my [health conditions]. I don’t see much of the GP.” Another said, “I think they sort all that side of things out, I’m seen by a [health professional] from the local surgery.”Members of staff did not always work well together, and we observed examples where people were sat for long periods alone, waiting for support. Staff were not always seen to interact with people or check on their well-being. There was a lack of leadership and modelling of expected practice.

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support. Some people did not always feel supported to manage their own health needs as much as possible. For example, one person told us, “I have queries over my [care] I spoke to staff here. One of the staff made me feel dreadful for querying my care. I’m not a rude person but they were very rude to me.” People were not always supported to be as physically active as possible to retain mobility and prevent deconditioning. We observed people sat for long periods of time and staff were task focussed. One person was over heard saying they were bored, another told us they wanted to get outside more.

There was no evidence of structured or meaningful activities aimed at supporting mobility, rehabilitation, or cognitive stimulation. Most people were sat within the communal lounge or within their bedrooms. At the time of the assessment there was no activity co-ordinator in place, but the provider had recruited a new one to start in September 2025.

Care plans did not always hold sufficient information to enable staff to have appropriate knowledge on any underlying health conditions of people. This would help staff to understand how to prevent and monitor for deterioration in their conditions.

There was limited evidence to demonstrate the provider was meeting people’s clinical or personal expectations. Care plans did not reflect person-centred objectives, and therefore there were no measurable achievements to track progress. As a result, it was unclear how the provider ensured that people’s personal or clinical needs were being understood or met. For example, body maps used to monitor people’s skin conditions were completed, but not always dated, so it was not possible to ascertain if skin conditions were improving or deteriorating.There were not always clearly documented interventions when people were found to be at high risk of skin damage. Another person had choked, but their choking risk assessment said they had not had any choking episodes. The lack of review meant that the person remained at risk without any actions taken to mitigate future risk. We found people’s care records had not been appropriately updated following changes in people’s conditions, abilities and needs and these records failed to give staff the clear and up to date information they needed to provide effective high-quality care.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment. The provider failed to ensure the correct procedure was followed in relation to the Mental Capacity Act 2005 (MCA). On reviewing people’s care records, we found examples where the provider had failed to ensure they acted in accordance with the legal requirements. For example, mental capacity assessments had not always been carried out when specific decisions needed to be made.

We found that for some people who had restrictive measures in place, such as movement sensors, decisions to review these were either overdue or were not completed well to ascertain who was involved in the decision making, and if it was the least restrictive option. This indicated a lack of knowledge in relation to the Mental Capacity Act 2005.

We were unable to review any DoLS (Deprivation of Liberty Safeguards) applications as the provider did not send the relevant information to us. The provider told us applications had been made, but we were unable to review any relevant conditions that may be in place.

CCTV (closed circuit television) was in use throughout the communal corridors, however, there was no reference to this in people’s care plans to ensure people were aware of its use. The provider told us they did verbally inform people and relatives of having CCTV on the premises, and they also had a policy in place regarding the purpose of the CCTV.

Most people said that staff asked for their permission before providing help. However, there were instances where people said staff did not always seek consent. One person said, “It depends, some staff do ask, some do not.” Therefore, we could not be assured people’s consent was gained appropriately and decisions made on their behalf were done in accordance with the requirements of the MCA.