You are here

Inspection Summary

Overall summary & rating


Updated 12 December 2017

We inspected this service on 31 October 2017. The inspection was unannounced. Baytree Lodge is a care home registered for a maximum of twelve adults who have mental health needs. At the time of our inspection there were eleven people living at the service. The residential care service is located in two large adjoining houses, on two floors with access to a back garden. The provider is also registered to provide personal care at a supported living unit for two people in a house next door. This inspection covered both services.

We previously carried out an unannounced comprehensive inspection on 27 September 2016 and found there were two breaches of regulations, one in relation to staffing and the other for the safe administration of medicines. We took action against the provider and issued a Warning Notice for the breach relating to medicines. We told the provider they must meet the requirements of this regulation by 28 November 2016. A focused inspection in January 2017 found the provider had met the requirements of the Warning Notice.

At the time of the inspection there was a registered manager in place. 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.

At this inspection we found the provider had ensured staff were provided with training in key areas and an up to date log of training was in place so the registered manager could ensure staff undertook refresher training as required. Supervision took place on a regular basis for staff.

The service assessed and managed risks relating to care delivery. Risk assessments were up to date and covered a broad range of risks. Care plans were person centred and contained detailed information on people’s preferences and routines.

People told us they were happy living at the service, and that staff were kind and caring. People received care and support from staff who responded to their individual needs and preferences, and who had the knowledge and skills needed for their care roles.

People were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible. The policies and systems in the service support this practice.

People living at the service, relatives and other health and social care professionals spoke highly of the registered manager and told us they were approachable and responsive to any issues raised. We could see the registered manager worked in partnership with health professionals to meet the needs of the people living at the service. Records showed that preparation and multidisciplinary working that had taken place to facilitate the smooth transition of a new person to the service.

Staff told us they felt supported in their role, and we could see from meeting records that the registered manager involved both staff and people living at the service in how the service was run.

Medicines were safely managed. People's finances were managed in an organised and effective way.

Staff understood the importance of safeguarding and the service had systems to help protect people from abuse and ensure safe staff recruitment practices occurred.

The service was clean throughout and there were hygiene controls in place to ensure that the kitchens were kept clean and food was safely stored. The provider was working through a plan of improvements to the service.

The registered manager undertook quality assurance audits in medicines and hygiene. The provider’s Quality and Systems Director undertook six monthly audits across a broad range of areas including finance, care planning and training. We could see when tasks highlighted from these actions plans were completed. In this way the service was seeking to continually improve the serv

Inspection areas



Updated 12 December 2017

The service was safe. Medicines were stored safely.

Staff were safely recruited.

People living at the service told us they felt safe living there.

Risk assessments were up to date and covered a range of identified risks.



Updated 12 December 2017

The service was effective. Staff had undertaken training in key areas and received regular supervision.

People had access to healthcare and the service worked in partnership with health professionals to support people’s good health.

Staff understood the importance of consent and appropriate documentation was in place for people whose liberty was restricted.



Updated 12 December 2017

The service was caring. We saw staff were kind and caring and people told us they enjoyed living at the service.

Staff understood people’s routines and supported them to be as independent as possible.

Records showed people were involved in the planning of their care and people told us they could give their views as to how the service ran.



Updated 12 December 2017

The service was responsive. Care plans were up to date, were person centred and gave details of people’s preferences and goals. Regular key working sessions took place to assist people in achieving these.

People were supported to attend activities and sports facilities locally. The service had recently set up art therapy classes and ran baking sessions at the service.

People told us they knew how to make a complaint.



Updated 12 December 2017

The service was well led. The registered manager had been working at the service for twelve months and had contributed positively to how the service was run.

The provider had effective quality assurance processes in place, and we saw regular audits took place in key areas.