Background to this inspection
Updated
23 November 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
Inspection team
The inspection was carried out by two inspectors, a medicines inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Baedling Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service did not have a manager registered with the Care Quality Commission. The manager was in the process of registering with CQC to become a registered manager. The provider, Alycone Healthcare North East Ltd, is legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
The inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used all this information to plan our inspection.
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make.
During the inspection
We spoke with four people who used the service, eight relatives, the nominated individual and staff including the manager, deputy managers, day and night care workers, the activities coordinator and the head chef. We also spoke with two health and social care professionals. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed a range of records. This included people’s care records, medicines records and information relating to staff recruitment and training. A variety of records relating to the management of the service, including policies and procedures were also examined.
After the inspection
We continued to seek clarification from the manager to validate evidence found. We looked at further information which they sent to us electronically. We spoke with three health and social care professionals and five relatives. We provided feedback to the local authority about our inspection findings.
Updated
23 November 2021
About the service
Baedling Manor is a residential care home providing accommodation and personal care for up to 54 older people. Accommodation was over three floors; Millfield, Hollymount and Chesters. Chesters was currently not being used, people resided in Millfield or Hollymount. At the time of this inspection 29 people were living at the home and in receipt of care and support.
People’s experience of using this service and what we found
A robust safeguarding system was still not in place following our previous two inspections in July 2020 and January 2021. The communication and recording systems within the home meant that not all safeguarding incidents were reported to the appropriate agencies in a timely manner.
An effective system to monitor and manage risks was still not in place. Shortfalls were identified with the safety of the premises; including fire safety, the water system and the security of the building. Government guidance relating to safe working practices including the appropriate use of Personal Protective Equipment (PPE) was not always followed.
Medicines were not managed safely. Records and medicines counts did not always demonstrate that medicines were always administered in line with prescribed instructions.
There were not enough suitably competent and skilled staff deployed. Staff told us and our observations confirmed, that staffing levels had affected person centred care and the provision of activities. There were gaps in the skills and knowledge of staff in areas such as, safeguarding people from the risk of abuse, infection control, care planning and meeting people’s nutrition and hydration needs.
A system to ensure regulatory requirements were met was still not in place. We identified shortfalls in many areas of the service including the assessment of risk, infection control, safeguarding people from the risk of abuse, staffing, training and governance.
There was a new manager and nominated individual in post. The new management team told us they were aware of the issues we had raised; but explained that due to the short period of time they had been at the home; there had been insufficient time to make all the necessary changes and embed these into practice.
Relatives spoke positively about the caring nature of the staff. Both people we spoke with told us they enjoyed living at the home. One person said, “I love it, I like this place, I just like all of it - everything about it is just lovely."
The provider was in early negotiations with a new provider about the possibility of taking over the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was inadequate following our inspection in January 2021 (published 2 March 2021). There were multiple breaches of regulation identified at that time.
We carried out a targeted inspection in April 2021 [published 29 May 2021] to look at IPC and recruitment procedures. Targeted inspections do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question. The overall rating for the service was not changed following this targeted inspection and remained inadequate. We took urgent enforcement action and imposed conditions upon the provider’s registration in relation to IPC.
At this inspection, sufficient action had not been taken to improve in all areas. There were ongoing and new breaches of the regulations.
Why we inspected
Prior to our inspection we received concerns in relation to infection control, safeguarding, staffing, medicines and the governance of the service. A decision was made for us to inspect and examine those concerns.
Enforcement
We are mindful of the impact of the Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the Covid-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, safeguarding people from abuse and improper treatment, staffing, duty of candour and good governance at this inspection. In addition, we also identified a breach of Regulation 19 of the Care Quality Commission (Registration) Regulations 2009 namely, fees.
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or varying the conditions of their registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.