Badby Park

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

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

This service scored 31 (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 have a proactive and positive culture of safety. They did not listen to concerns about safety. Lessons were not learnt to continually identify and embed good practice.

The provider had a reactive not proactive culture towards safety incidents.

There had been a number of incidents in the service that had impacted on people that the provider had not learnt from and acted to mitigate future risk to others. For example, there had been an incident where a person’s emergency medical equipment had not being available on site due to an oversight when ordering.

The provider had completed a full investigation and understood what had gone wrong and mitigated further risk for that person. However, this had not prompted the provider to establish if there was a risk of similar incidents to other people and a further incident occurred where an emergency medication was not available for a person when required.

Where a person had experienced a fall, despite staff reports suggesting a potential equipment fault, the provider failed to take the equipment out of use pending a professional engineer’s assessment.

Although all staff were aware how to report incidents and accidents, some staff told us there was reluctance to report incidents for fear of retribution due to a blame culture within the home.

Details of accidents and incidents were shared with staff at team meetings and handovers.

The provider had not always worked well with families to support transitions into hospital.

The provider had a system and process in place for emergency transitions into hospital. A relative told us staff had accompanied their relative to hospital and stayed with them until they were admitted to a ward.

However, some relatives had not been informed of hospital admissions which had impacted on the support they were able to offer their relative at a stressful and worrying time. One relative told us, “The communication is shockingly lacking now”. There had been a significant delay from the care home in updating the relative and they had heard directly from the hospital about the admission for their relative. They had found this particularly upsetting as the hospital were asking the family to make decisions regarding end of life care when they had been unaware their relative was ill in hospital. Other relatives felt they had been informed promptly of hospital admissions. This supported that there was inconsistency across units in the service.

Some people within the home were on rehabilitation pathways supported by internal staff such as physiotherapy and occupational therapist. One relative told us that there had been an improvement in their relative’s ability to communicate as the service had provided a number of aids to support. They explained the positive impact this had had on their wellbeing. Another relative told us that their relative had progressed to being able to eat without the support of a feeding tube.

The provider had a system in place to report safeguarding concerns and staff had received training in safeguarding adults and children.

The provider shared concerns appropriately with the local authority and Care Quality Commission, however, lessons were not always learned following accidents and incidents to safeguard people from further harm.

We found that where one person had a condition on their Deprivation of Liberty Safeguard (DoLS) that must be met, the provider and staff had not ensured the condition was met and had therefore deprived a person of their liberty.

People told us they felt safe with staff and staff were kind and caring. A relative told us that they had witnessed unprofessional conduct of a staff member towards a person living in the home, they had felt confident to raise the issue and believed it was dealt with promptly.

The provider did not manage risks well. Staff did not provide care to meet people’s needs that was safe. People were not protected from the risk of harm.

Staff told us and we observed they had instant access to people’s risk assessment and care plans via an electronic system. However, where risks to people had been identified staff did not always ensure they were mitigated. For example, one person had a health condition that required regular scheduled monitoring of their equipment and recording of result to provide information to medical specialists for monitoring health and planning future care. Records evidenced this activity had not always been completed as scheduled. This meant there was an increased risk of medical professional not receiving the information required to support the person. We also found that routine checks and tasks for peoples care and safety were not always completed including, ensuring that pressure relieving equipment was set correctly and feeding tubes (percutaneous endoscopic gastrostomy) were monitored and managed safely.

Risk assessments were completed and reviewed regularly. However, some contained conflicting information. For example, a person’s diabetic care plan did not provide staff with clear guidance on how to support the person safely. We also found conflicting information in persons food and nutrition care plan that described them as needing small and bite sized foods but also that they were nil by mouth and supported to eat via a specialist feeding tube. This meant staff did not have clear guidance to mitigate risk.

We received mixed feedback from people and relatives on their involvement in managing risk and we found that positive risk taking varied across units. For example, one person told us they were not involved in planning their care and did not know if risk assessments were reviewed regularly.

A relative gave us an example of positive risk taking, they said, “I like to give [relative] drinks, and staff showed me how to do this, so I understand how it should be”, they were pleased they had been included and involved in supporting their loved one. Another relative told us they had not been involved in assessing risk and planning care with the home for a number of years, they told us the only input they got was with reviews by the funding local authority.

The provider did not detect and control potential risks in the care environment to support the delivery of safe care.

People were not protected from risk in the event of a fire. We found a number of towels used as wedges to prevent fire doors from closing. We raised this practice with the registered manager who failed to address this and at our next visits this practice was still in place. Portable heaters were found in the service despite a fire risk assessment advising that they should be removed from the service due to the risk of fire.

People had personal emergency evacuation plans (PEEPS); however, we found they did not include guidance for staff on what action to take where people did not have automatic fire door closures. The room numbers on these records did not always match the emergency grab sheet that would be shared with emergency services if needed for evacuation purposes. This meant there was risk of confusion during a fire or emergency evacuation.

A number of routine safety checks of the environment were either inconstant or not complete. For example, we found incomplete records for hot and cold water temperatures, no evidence that water outlets in dormant areas were being flushed as scheduled and no evidence that risks highlighted in a legionella risk assessment had been completed. This increased the risk of legionella in the service.

The building was in need of repair to prevent further water ingress and damp. We found there were visible damp patches in communal areas and some peoples rooms.

A staff member told us that maintenance staff were stretched for time so prioritised immediate repairs. We were told the provider did not have the support of a regular gardener and we observed the grounds to be unkempt and in some areas hazardous.
 

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There was no evidence that staff recruited during the period of January 2025 to the start of our inspection in September 2025 had received an induction into the service. There was no clear plan on how many staff were affected or how those staff would be supported to ensure they had access to the information needed to carry out their role safely.

The provider’s records evidenced that there had been delays in ensuring compliance with training and competency checks for qualified nursing staff in carrying out clinical tasks. For example, stoma care, catheterisation and syringe drivers. There had been incidents in the home resulting from poor staff practice. Staff supervisions evidenced that staff had raised concerns about some of the practices in the home but there was no evidence of how the provider had acted on those concerns.

The provider did not have an effective system to calculate staffing numbers and we observed staff to be struggling to fulfill a number of tasks at a time. For example, staff were seen leaving people mid support with eating a meal to support other people having altercations or needing personal care. Some people were sat for an extended period of time waiting for support with eating at meal times. There were no activities staff employed by the service which meant occupational therapy staff were supporting units at lunch times and providing some activities as and when their time constraints allowed.

Some staff members said there were not enough staff, care was task focused and that staffing levels were usually enough to meet people’s needs. A staff member said, “Sometimes it can be harder at very busy times, like mornings or mealtimes, but we work together to manage”. A person told us there were not enough staff, when asked why they felt that they said, “Because they tell me, they say I can’t do you yet for another hour, we haven’t got enough staff”. The person said there were less staff at the weekends and some people and relatives agreed with that.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

Staff had received training in infection control and used personal protective equipment (PPE) appropriately although some dispensers were noted to have limited sizes of gloves available for staff use. Hand washing facilities were available and we observed staff to wash their hands and change PPE between tasks.

However, there was evidence of a rat infestation in the homes rubbish disposal area that was not being effectively managed to reduce the risk. Although there was evidence of some professional pest control input, we found the advice given by the professionals to ensure rubbish was appropriately managed was not followed and the infestation had continued over a prolonged period of time. There was a risk of rats entering the building and we observed the natural run to some bait stations was blocked with debris. We found the kitchen door and some ground floor doors and windows to people’s rooms were open and one member of the inspection team observed and prevented a rat from entering a ground floor window. Another member of the team encountered live rats in the grounds between buildings and in waste bins among the rubbish. This increased the risk to people.

Clinical waste was not always appropriately managed and we found bins in the rubbish disposal area to be unlocked and wide open allowing access to pests, accidental contact or deliberate interference.

Records evidenced that cleaning was not being completed as scheduled. Although the notes within records gave the reason for non-compliance as there not being enough staff available, the provider had not deployed extra staff to ensure the risk of infection was minimised.

There were no cleaning records or schedules available for the laundry meaning staff did not have clear guidance for this area. However, except for some sticky flooring on one of the units the home was found to be visibly clean and odour free. People and their relatives told us the home was clean.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People were given their medicines and this was recorded on their medicines administration record (MAR). The staff treated people with care when medicines were administered. However, we saw on a medicines administration round, dispensed medicines were left unattended on the trolley by the nurse. We also saw that a MAR chart was signed as given before the medicines had been administered. This meant records did not accurately reflect administration and the risk of errors was increased.

MAR sheets were seen to have hole punches to allow filling in the folder, however, we saw examples where the hole made the medicine name unreadable. In these cases, the medicine was then re-written on by hand. This increased risk of errors when rewriting medicine names.

Following a recent incident, where medicines delivered from the pharmacy were incorrectly thought to be missing, the provider had not improved their processes for timely checks of medicines coming in. Medicines that had been delivered by the pharmacy were observed to be stored in cardboard boxes in a medicine room on one unit The boxes had not been opened to check what had been delivered from 3 days ago.

We found that a medicine prescribed for multiple people was stored in a single drawer. We also found that different brands of the same medicine had been mixed together in one person’s box. Storing multiple people’s medicines in the same drawer and mixing brands increases the risk of errors, such as making mistakes when administering doses.

When medicines were given covertly (disguised in food or drink), pharmaceutical advice was not always available on how these medicines should be administered