Archived: Bay House

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

We found 2 breaches of the legal regulations in relation to safe care and treatment and safeguarding.

Staff did not always assess risks to people’s health and safety or mitigate them where identified. The environment was not maintained to a suitable standard placing people at risk. People were not protected from risks associated with infection prevention and control. People were not always safeguarded from the risk of abuse. The provider did not promote a learning culture. Medicines were not always managed safely. Staff were not sufficiently trained.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives told us the provider had been open in discussing the concerns found during the last inspection. Relatives also told us staff were proactive in making contact with them if their relatives needs changed.

Staff told us they would raise any concerns with the manager and a meeting would be arranged to communicate any lessons learned.

However, we found examples where concerns had been documented but not escalated to the management team.

The provider did not promote a learning culture in the service. Incidents were not actively investigated to identify lessons learned and drive improvements.

Staff did not report incidents effectively which led to an increased risk these could be missed and no follow up action could be taken.

The provider had a service improvement plan in place following feedback during the last inspection and from the local authority, however these failed to capture and address fully the issues identified at the previous and during this inspection.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were not always listened to and where people had raised concerns these were not always followed up appropriately. However, people and relatives told us they felt safe. One person said, “I am safe as I could be, people are around me and I get the help I need.”

Staff were able to tell us what situations would require a safeguarding referral and were able to give examples, such as unexplained bruising and medicine errors. However, we found incidents recorded in people’s care records which had not always been reported to the relevant authorities.

People were not always protected from the risk of harm or abuse. During our site visit one person raised concerns with inspectors, we also found this person had raised similar concerns to staff which had been recorded in care records. When we raised this with staff they did not recognise this information needed to be reported to the local authority safeguarding team. We also found multiple areas of disrepair and infection control concerns in the service placing people at risk, we have reported on this in detail in the IPC and safe environments quality statements.

There was a safeguarding policy in place with clear processes, however this was not always followed by staff and leaders.

The provider failed to identify some incidents which required a safeguarding notification, for example, unexplained bruising. This meant people were not protected from the risk of abuse.

People and relatives told us they were involved in care planning. One relative said, “I was fully involved (in relatives care plan) I tried to explain to my relative every step, we are constantly updating forms and the manager is checking if anything is missing.”

Staff were not able to explain how they supported people to manage risk and did not recognise risks to people identified during this inspection.

Staff told us they had recently moved to completing risk assessments online and had been focusing on the most important ones first, for example, bedrails. We found that whist these assessments were in place they were not always being followed by staff.

Staff told us they regularly discussed any changes to people's needs during handover and were involved in updating care plans where needed.

We observed the kitchen area was unsecured. You could access an external door, the staff room, and the laundry via the kitchen, which we found unsecured throughout our inspection visit. This placed people at risk of leaving the service without staff knowledge and placed people at risk as they could access areas of the service where risks were present. We also found a number of environmental risks, we have reported on this further in the safe environments quality statement.

The provider failed to assess the risk to the health and safety of people using the service.

Risk assessments were not always in place or did not contain enough detail, which meant mitigation measures to keep people safe were not always known to staff. For example, we found bed rails had not been suitably assessed and presented a risk people could become injured. We also found a 1st floor fire escape was accessible and presented a risk of falls from height. The provider failed to identify this.

People were not protected against the risk of substances hazardous to health. We found chemicals, for example absorption granules, denture cleaning tablets and large quantities of alcohol gel, easily accessible to people. There was no risk assessment in place. There was a risk people could ingest these items causing harm.

People and relatives said they felt the environment was safe.

One person told us, “I love my room, very safe, big and clean.”

A relative said, “We love [Bay House], we didn't think anything was wrong with Bay House before but we do notice that it is cleaner and tidier now."

Staff failed to recognise the environmental issues we identified. Although staff told us about the improvements made since the last inspection, significant concerns remained and staff did not understand why the current environment was still unsuitable.

The environment was unsafe placing people at risk of harm.

We found fire doors did not always work correctly, for example they were missing smoke seals or did not close correctly. This placed people at risk as the fire doors would not work effectively in the event of a fire. We found an emergency escape exit did not operate correctly; this placed people at risk in the event of an emergency evacuation.

The provider failed to assess environmental risks to people. We found a 1st floor fire escape was easily accessible, we also found missing window restrictors, where window restrictors were fitted, these did not meet health and safety executive requirements. This presented a risk of falls from height.

We observed multiple areas of disrepair in the service. For example, damaged and rotten flooring in a bedroom, lifting carpet that had evidence of mould and broken hand soap dispensers. We also noted several bedrooms where there was an abundance of items that could increase a person’s risk of injury and falls.

Processes were ineffective in ensuring a safe environment.

Whilst the provider had completed a number of required checks, for example, fire risk assessments, gas and electrical certification. We found there was limited process in place to make sure the environment was safe, where processes were in place, these were ineffective. For example, we viewed records relating to water testing and found this did not capture all areas required. We also noted the fire door checks and bed rail checklist had not identified the areas observed during the inspection visit.

People and relative told us there were enough staff.

One relative said, “[Staff] are all working at high standards and are genuinely lovely people.”

Staff told us they were well supported by the management team and received regular training and supervision.

Staff told us they had enough staff on duty to meet people’s needs. One staff member said, “We definitely have enough staff, we are overstaffed actually, for the amount of people living here”.

Whilst we observed enough staff to meet people's needs during our visits. We noted there was a lack of meaningful engagement at times. For example, we observed the communal lounge over a full 1-hour period and there was minimal interaction with people other than to offer a drink.

Staff were not sufficiently trained.

We reviewed the training matrix, whilst this confirmed staff had completed a number of training courses, there were also a significant number of gaps. The training matrix was not clear on what training was required and by when, this meant the provider could be clear when staff training was required.

The training matrix stated that all staff should complete the care certificate if they started after 2017. We found 4 staff who had not completed this training despite them starting after 2017. This meant people were at risk of being supported by untrained staff.

We found only 3 out of 17 staff members had completed catheter care training despite the service supporting people with catheter care. This place people at risk as staff were not trained to support catheter management.

The providers policy was to renew disclosure and barring checks (DBS)every 3 years. The training matrix we were provided showed 10 staff members were overdue their DBS check.

People and relatives did not raise any concerns with IPC, they told us recent changes had improved the service. One relative told us, “There are good changes everything is now clean, walls are freshly painted and there is no bad smell.”

Staff told us they had access to appropriate personal protective equipment. They told us they completed regular walk arounds of the service with the manager and believed the service was clean to a suitable standard.

Staff did not raise any concerns about the environment; however, we found some areas of the environment were unsafe and poorly kept, indicating the staff did not recognise these issues as a risk to people.

People were not protected from risks associated with infection prevention and control.

Areas of the service were visibly dirty and could not be suitably cleaned. For example, we found damaged flooring, multiple commodes were visibly dirty and rusty, we found staining on a wall, floor and bed bumper, dirty wash bowls in bedrooms, rusty and dirty privacy screen, damaged sink and walls in bedrooms, stained bed base, chipped wood areas on overlap tables and furniture. This put people at risk of infection and ill health.

We observed staff wearing rings, watches and bracelets. This was not in line with the providers policy and increased the risk people could be exposed to infection due to poor hand hygiene.

People were not protected from risks associated with infection prevention and control.

The provider had a cleaning schedule in place, however we found this was not effective in maintaining a suitably clean environment.

The provider had an infection prevention and control policy in place.

Processes to monitor infection prevention and control measures were ineffective. The provider had an “IPC” audit in place, however this failed to identify the areas noted during the inspection.

To reduce the risk of legionnaires disease, the providers risk assessment stated unused water outlets, such as sinks should be flushed weekly. Records reviewed showed only 1 of the empty rooms had been flushed recently. This placed people at risk of infection.

People told us they received their medicines as required, on time.

Staff received training for medicines administration, this included a competency assessment with a senior staff member.

Not enough improvement had been made since our last inspection, we found concerns in relation to the management of topical medicines during this inspection.

We found topical medicines that did not belong to the person in bedrooms. This meant people may have received topical medicines that were not suitable for them and increased the risk of infection as the creams may have been shared.

Topical medicines did not have clear directions for staff to follow. Topical medicines for 2 people stated “as directed” with no further information to direct staff where and how often they should be applied. This meant people may not have received their medicines as prescribed.