Archived: Baedling Manor

Baedling Manor is a residential care home providing accommodation and personal care to up to 54 older people. At the time of this inspection 41 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 inspection. Staff said they would report any concerns to the management team, but we found these safeguarding concerns were not always reported to the appropriate external agencies in a consistent way.

Safe and effective infection control systems and procedures were not fully in place to ensure people were protected from the risk of infection. Government guidance relating to safe working practices including the appropriate use of Personal Protective Equipment [ PPE] and hand hygiene, was not always followed by staff. This placed people at risk of infection which is of particular concern during this time of a national pandemic.

Medicines were not managed safely. There were inaccuracies and omissions with the administration and recording of medicines. Medicines administration records did not always demonstrate that medicines had been administered appropriately and as prescribed.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests. Although policies and procedures were in place, systems were not always followed.

Staff training was not up to date. There were gaps in the skills and knowledge of staff across multiple areas of the service. The provider had stopped using their former training agency in October 2020. They had arranged to use a new training company from January 2021. A training plan was in place.

People we spoke with told us they were happy and enjoyed living at the home. Most relatives also spoke positively about the caring nature of the care staff. The language used by some staff in care records did not always promote people's dignity. We have made a recommendation that the provider ensures best practice guidance is followed with regards to the language and terminology used within care records.

An effective complaints system was not in place. Several relatives stated that they had not received a response to their complaint.

People’s social needs were met. An activities coordinator was employed. She spoke enthusiastically about meeting people’s social needs. Due to the current Covid-19 pandemic, people had not been able to go out into the local community; activities had therefore taken place in the home.

Several staff described a closed culture at the home where they did not always feel able to raise issues and concerns. We received concerns from a number of sources about the manner and approach of the director which they said did not always reflect the ethos and values of the service.

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, Mental Capacity Act [2005], training, the management of complaints and governance/management oversight. In addition, an effective system to ensure that all notifications were submitted to the CQC in a timely manner was still not fully in place. This failure to notify the CQC of incidents and other matters in line with requirements meant people were exposed to a risk of harm as there had been no overview by CQC to check whether the appropriate actions had been taken.

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 requires improvement (published 11 September 2020). There were multiple breaches of regulation identified at that time. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, sufficient improvement had not been made and the provider remained in breach of the regulations.

Why we inspected

Prior to our inspection we received concerns in relation to safeguarding, staffing, medicines, complaints and the governance of the service. A decision was made for us to inspect and examine those concerns. The inspection was also carried out to check that the provider had followed their action plan and confirm they now met legal requirements.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to the coronavirus (Covid-19) and other infection outbreaks effectively.

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 six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the need for consent, safe care and treatment, safeguarding people from abuse and improper treatment, staffing (training), receiving and acting on complaints and good governance of the service at this inspection. In addition, we also identified a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 namely, Notification of other incidents.

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 is therefore 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.

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.

Baedling Manor is a residential care home providing accommodation and personal care to up to 54 older people some of whom are living with a dementia related condition. At the time of our inspection 35 people were living at the home. Accommodation is provided across three floors.

People’s experience of using this service and what we found

People were not protected from the risk of harm. Staff did not always follow government guidance in relation to safe infection prevention and control [IPC] procedures and risk assessments did not contain specific information in relation to the potential impact to people from the COVID-19 infection.

Risk assessments were not in place to support safe indoor visits by relatives. We shared these concerns with the local authority commissioning team who liaised with the home to suspend visits until risk assessments were agreed and could be implemented.

Records confirmed staff had been recruited safely.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was inadequate (published 2 March 2021).

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about the infection prevention and control [IPC] practices within the home and recruitment of staff. A decision was made for us to inspect and examine those risks. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

CQC have introduced targeted inspections to check specific concerns. They 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.

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 have identified one breach in relation to safe care and treatment at this inspection.

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

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Baedling Manor is a residential care home providing accommodation and personal care to 54 older people. At the time of this inspection 49 people lived at the home.

People’s experience of using this service and what we found

We received mixed feedback from people, relatives, staff and visitors. Issues and concerns were raised about the safety, effectiveness and management of the service.

People did not always experience safe care and treatment. The provider had not done enough to assess, monitor and mitigate risks related to people’s health and safety.

There was not always not enough suitable staff deployed to safely meet people’s needs. Staff training was not up to date and staff had not been routinely supervised. The staff recruitment process needed to be more robust. We have made a recommendation about staff recruitment.

People were not always safeguarded from the risk of harm. Incidents were not reported or recorded properly, and action was not always taken to address matters. The home was placed into organisational safeguarding by the local authority and there were police investigations in progress. This meant the local authority was monitoring the home and supporting them to ensure the correct procedures were in place to keep people safe.

Staff did not always work in accordance with the Mental Capacity Act 2005 (MCA). Deprivation of Liberty Safeguards (DoLS) were not properly monitored and managed in line with the MCA code of conduct.

Consent was not always sought from the relevant person. People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests. Although policies and procedures were in place, systems were not always followed.

There was no registered manager at this service. Audits and checks of the service were inconsistent and, in some cases, they had not been completed for some time. Consequently, the provider did not have robust oversight of the service. The new manager had identified some shortfalls and started to implement change and improvements.

The systems in place had not always been effectively managed to ensure care was delivered in line with standards, guidance and the law. The provider had not notified CQC of some events which they were legally required to do so.

Staff worked alongside external health professionals to support people’s health and well-being.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 15 March 2019).

Why we inspected

We received concerns in relation to safeguarding people, staffing, recruitment, medicines, infection control, consent, complaints and the governance of the service. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. Ratings from previous comprehensive inspections for the key questions we did not inspect were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe, effective and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Baedling Manor on our website at www.cqc.org.uk.

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 have 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 the risk of harm, people’s consent to their care and support, staffing and the overall governance of the service at this inspection. In addition, we also identified a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 namely, Notification of other incidents.

Follow up

We have requested an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service: We found people were receiving safe care at the time of the inspection. Action had been taken to address the concerns that had been raised.

We found audits and checks continued to be carried out but they had not picked up on all the issues we identified during the inspection. We have made a recommendation about closely monitoring the effectiveness of governance systems, particularly with the increase in numbers of people using the service.

Rating at last inspection: Good (report published 17 July 2018)

Why we inspected: We carried out an unannounced comprehensive inspection of this service on 22 May 2018. More recently, we received concerns in relation to the management of medicines, pressure ulcers, staffing and infection control. As a result, we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to these topics. We looked at the key questions ‘Is this service safe?’ and ‘Is this service well-led?’

We did not inspect the key questions ‘Is this service effective, caring, or responsive’ as our ongoing monitoring did not raise any information about risks or concerns in these areas.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate and high quality care. Further inspections will be planned for future dates.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Baedling Manor is a 'care home' People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home can accommodate up to 50 people. There were 26 people living at the home at the time of the inspection.

This was the first inspection of the home since the service first registered with the Care Quality Commission [CQC] in June 2017.

A registered manager was in post. A registered manager is a person who has registered with the CQC 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 and associated Regulations about how the service is run.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. The local authority safeguarding team told us that there were no organisational safeguarding concerns regarding the home.

The furnishings and fittings were luxurious and all areas of the building were well maintained. People and relatives were very complimentary about the premises. One person told us, “It’s like a five star hotel.”

There were sufficient staff deployed. Safe recruitment procedures were followed and staff had completed training in safe working practices. There were safe systems in place to receive, store, administer and dispose of medicines.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in place supported this practice. The registered manager was strengthening the home’s documentation to ensure that records reflected how the Mental Capacity Act [2005] was followed in practice.

We observed that staff supported people with their dietary requirements. We spoke with the head chef and chef who spoke passionately about ensuring people’s nutritional needs were met and that the meals provided at the home were of the highest standard.

Staff were motivated and committed and spoke with pride about the importance of ensuring people's needs were held in the forefront of everything they did. One staff member told us, “It’s passionate care here.”

Staff were knowledgeable about people’s preferences and life histories. We have made a recommendation that people’s electronic care plans reflect this information.

There was an activities coordinator employed to help meet the social needs of people. A varied activities programme was in place. The home was part of the local community. The hair and beauty salon and café were open to the public.

People and relatives spoke positively about the home. One relative told us, “It is a modern way of looking at care; a lot of thought has been put into it.” All staff informed us they were happy working at the service and morale was good and they enjoyed working at the home. We observed that this positivity was reflected in the care and support which staff provided throughout the day.

Regular audits and checks were carried out to monitor all aspects of the service. Feedback systems were in place to obtain people and their representatives’ views.