North Bay House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question Inadequate. At this inspection the rating has changed to requires improvement. This meant the management and leadership was inconsistent.

At the previous inspection the provider was in breach of the legal regulation relating to Governance and failure to notify CQC of significant events. The provider had made improvements with notifying CQC of reportable events and is no longer in breach of this legal regulation.

Although some improvements were noted in relation to the governance of the service, the provider remained in breach of this legal regulation.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The culture in the service had improved. The provider was working towards building a culture that focused on enabling people to enjoy their lives and have more opportunity to take part in activities of their choosing. Whilst work was still underway, it was positive to see that actions had made a difference to people’s experience of their care. This was also reflected in relative’s feedback about the service. One relative told us, “The activities level has really increased, and the [residents] seem far more engaged with them now. The minibus is a great boost as not many homes have those. Even the larger ones. The carers seem to work well together, and the overall spirit of the place is good.” Another said, “[Regional manager] is there a good amount of time now and a lot of overseeing has gone on. Each of them has a role and they seem to keep an eye on each other.” A third told us, “New staff have been appointed since the [CQC] report and they seem very good. There has also been a very noticeable presence of the owner who is superb. Out there on the floor, very hands-on and working late. In fact, I have seen the whole family [provider] at various times.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, however, the registered manager had only been in post since September 2025, and there was a significant amount of work to do to ensure a high quality of care was delivered. The registered manager was realistic about how far the service had come, and recognised further improvements were still needed. Audits had not always identified the concerns we found, and accidents and incidents required a more in-depth review to ensure risk was fully mitigated.

The provider was open about issues identified within the service and they were responsive to feedback received both during and following our assessment. There were action plans in place. Most staff told us the management team was visible and approachable, and appreciated the improvements made since the last inspection. Staff received training relevant to their role, but further work was needed by the management team to ensure staff had understood the training they received. The registered manager was aware of the need for this and was planning further checks. Supervision records were sometimes brief in content and would be an opportunity to test staff knowledge during one-to-one meetings.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt confident to raise concerns if needed and they would be listened to. One staff member said, “I can speak with [registered manager or regional manager] if I need to. Both would be available to me if I needed.” Comments from staff in the most recent staff survey (May 2026) included, “We have a great team now and management is better”, and, “The team are pulling together to overcome issues raised by CQC and safeguarding.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. In the main, staff we spoke with told us they felt valued and were not treated unfairly. Staff had completed equality and diversity training. Equality and diversity training is essential to create a safe, respectful, and inclusive environment for people and staff, ensuring that everyone receives the care and support they deserve.

There was evidence of staff meetings and supervisions to show staff had a forum to raise any concerns. There was an ‘employee of the year’ scheme in place which was announced at the company Christmas party with a bonus for the winner.

The provider did not consistently demonstrate effective governance arrangements. Despite there being multiple audits in place, some of which identified where improvements were needed, they were not always sufficiently robust to enable the provider to identify all of the issues we found. Issues such as unsafe toileting equipment and infection control issues were not identified. Care plan audits failed to identify where risk assessments were needed. Where care plan audits had identified issues in records, the corresponding action plan was sometimes blank. This did not evidence that issues were rectified promptly. The monthly analysis for accidents and incidents contained a section on ‘skin damage’ and ‘pressure ulcers’. However, none of the current skin conditions people had were noted on this. Having this helps to give an overview to identify how the wounds occurred, if improvements were seen month on month, identify the root cause and share any lessons learned. ‘Recommendations to prevent similar incidents in the future’ were not always completed.

Some records were not kept securely at all times. We found some choking risk assessments were kept in a folder in the dining room throughout the day which were accessible to anyone who went into the room. However, the provider informed us that the paper risk assessments would no longer be required, as the choking risk assessments would be accessible to staff on the new electronic care planning system.

On day 2 of the inspection we found the provider had addressed the issues we raised related to health and safety and infection control measures, however the provider’s own audits had failed to identify the concerns independently, some of which placed service users at risk of harm. Providers must ensure that their audit and governance systems remain effective.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. People were supported to be part of the local community and visited local places for days out, such as fish and chips at the seaside, or a boat trip in the local area. People were referred to other agencies when needed and staff understood their responsibility to share information to support them.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. Staff described recent improvements in training and support since the registered manager’s appointment. However, these approaches were not yet evaluated. For example, some staff lacked knowledge in the Mental Capacity Act 2005, and safeguarding, despite having undertaken the training. As a result, the service could not fully demonstrate that learning and improvement were fully embedded or that changes were leading to sustained improvements in people’s care and experience.

Despite this, the registered manager did focus on continuous learning, and as such had implemented training such as an ‘age simulation suit’ which helped staff to experience how ageing and dementia can affect people in their day to day lives. The provider told us this had a positive effect on staff who said they were able to understand much better the challenges older people may face when their sensory abilities decline. There was a plan in place to drive improvement within the service.