Archived: Baycroft Grays Farm Road

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

We found a breach of our regulations at this inspection because the providers system for monitoring the quality and safety of the service had not ensured that medicine administration records (MARs) were completed accurately. This is despite our findings at out last inspection in August 2019 where we reported that improvement was required to ensure medicine administration records (MARs) were always completed accurately.

People told us they felt safe. There were safeguarding policies and procedures in place and staff had a clear understanding of these procedures. Appropriate recruitment checks took place before staff started work and there were enough staff available to meet people’s care and support needs. Risks to people were assessed and staff were aware of the action to take to minimise risks where they had been identified. The service had procedures in place to reduce the risk of infections and COVID 19.

The provider took people’s views into account through satisfaction surveys and feedback from these was used to improve the service. People and their relatives were positive about the service they received. Staff said they received good support from the registered manager. The registered manager and staff worked with health and social care providers to deliver an effective service.

Rating at last inspection

The last rating for this service was requires improvement (published 25 September 2019) as we found a breach of our regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We received concerns in relation to people’s nursing care needs and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained the same. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvements. 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

Baycroft Grays Farm Road on our website at www.cqc.org.uk.

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 with the 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.

Baycroft Grays Farm Road is a care home providing personal and nursing care to up to 75 people. There were 35 people receiving support at the time of our inspection. The home accommodates people across three floors. One of the floors specialises in providing care for people living with dementia.

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

Risks to people were not always safely managed. People received their medicines as prescribed, but improvement was required to ensure medicine administration records (MARs) were always completed accurately. The provider had systems in place to help monitor the quality and safety of the service, but improvement was required to ensure these consistently helped identify issues and drive service improvements. The home had been designed and adapted in ways which helped meet people’s needs and work was ongoing to ensure the needs of people living with dementia were fully met.

We have made a recommendation about adapting the service to better meet the needs of people living with dementia.

People told us they felt safe living at the home. Staff were aware of the provider’s safeguarding and whistle blowing procedures. The manager had made appropriate safeguarding referrals to the local authority where concerns had been raised. Staff received training in infection control and knew the action to take to reduce the risk of the spread of infection. There were enough staff deployed to meet people’s needs. The provider followed safe recruitment practices. The manager reviewed the details of any accident or incidents that occurred for learning, to improve safety.

People’s needs were assessed before they moved into the home. Staff sought people’s consent when offering them support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People had access to a range of healthcare services when required. The provider worked with other agencies to ensure people received effective care and support.

People were supported to maintain a balanced diet and they told us they enjoyed the meals on offer at the service. Staff were supported in their roles through an induction, training and regular supervision. Staff treated people with dignity and respected their privacy. People told us staff were kind and considerate. Staff involved people in making decisions about the care they received.

People had been involved in the planning of their care and received support which reflected their individual needs and preferences. They had access to a range of activities at the home and were supported to maintain the relationships that were important to them. The provider had a complaints procedure which was shared with people when they moved into the home and people expressed confidence that any issues they raised would be dealt with appropriately.

The manager demonstrated a good understanding of the responsibilities of the role. Staff told us they felt well supported by the management team and each other. They told us they worked well as a team and we noted that the service had a positive working culture. The provider sought people’s views through regular meetings and the use of surveys. The manager acted to make service improvements based on any feedback.

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 23 August 2018) and there were breaches of three regulations in respect of the safe management of medicines, staffing and good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made to address the three regulatory breaches we had previously identified. However further improvement was required in respect of good governance and the safe management of medicines. We also identified a breach of regulations because risks to people were not always managed safely.

The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified a breach in relation to safe care and treatment at this inspection because risks to people were not always managed safely.

Please see the action we have told the provider to take at the end of this report.

Follow up

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 with the 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.

Baycroft Grays Farm Road provides residential, nursing and dementia care and support for up to 75 older people. The service also offers short stay respite care. Accommodation is spread over three floors connected by internal lifts throughout. At the time of our inspection there were 31 people using the service. There was no registered manager in post at the time of our inspection, however, a general manager was in post to oversee the day to day management of the service until a registered manager is appointed. 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 three breaches of regulations because the management of medicines within the home was not always safe or in line with best practice, staff were not always supported in their roles through regular appropriate training, supervision or appraisals of their practice and performance and systems and processes in place to monitor the quality and safety of the service were not always effective or well-led. We also found several areas that required some improvement including the monitoring of safeguarding, accidents and incidents and complaints, staff deployment within the home and the provider’s nurse call system, areas of the environment and some improvement was required to enhance people’s meal time experience. We will check on the progress of these areas at our next inspection of the service.

You can see what action we told the provider to take at the back of the full version of the report.

People were protected from the risk of abuse as staff we spoke with demonstrated a clear understanding of how to safeguard people from abuse, the signs they would look for and what they would do if they thought someone was at risk of abuse. Staff had identified concerns and recorded accidents and incidents appropriately seeking medical attention when required. Appropriate recruitment checks took place before staff started work. There were arrangements in place to deal with foreseeable emergencies and there were systems in place to manage infection, clinical waste, gas and electrical appliances and water safety. Risks to people were assessed to help keep them safe and the home environment was clean and appropriately maintained.

Staff completed an induction programme which included induction training when they started work. People’s dietary needs, risks and personal preferences were met and respected. Staff were knowledgeable about people’s dietary needs and advice from health care professionals was sought when required. The home is newly built and suitably designed to meet some people’s needs. Pre-admission assessments of people’s individual care needs and preferences were completed before they moved into the home to ensure staff and the home environment could meet their needs safely and appropriately. People and their relatives told us staff supported them to access health and social care professionals when required and monitored their health to ensure their wellbeing. 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 the service supported this practice. Staff were aware of the importance of obtaining consent from people when offering support and worked within the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

People and their relatives told us staff were friendly, supportive and caring and they were provided with information about the service when they moved into the home. During our inspection we observed positive and caring interactions between people and staff and people were supported to maintain relationships that were important to them. Relatives and visitors told us they were made to feel welcome when they visited the home.

There was a range of facilities and activities offered to people to support their need for social interaction and stimulation. People and their relatives told us they received care and support in response to their needs and they were involved in planning, managing and making decisions about their care. Care plans documented the support people required and contained guidance for staff to ensure support was offered to people appropriately. People’s diverse needs were respected and care plans included details about people's needs in relation to age, disability, gender and religion. However, we noted that care plans lacked detail in areas other than religion such as race, sexual orientation and culture.

There were some systems in place to seek the views of people using the service and their relatives through residents and relative’s meetings and surveys. However, surveys were yet to be implemented and sent to people and their relatives to complete. The home worked in partnership with health and social care professionals to ensure people received appropriate support to meet their needs.