Baylham Care Centre

Baylham Care Centre is a care home with nursing. At the time of our inspection 39 people were being provided with care and support which included younger adults and older people, some of whom have complex mental health and physical needs. The service can support up to 55 people.

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

Overall, the provider had improved their quality monitoring systems. However, they could not evidence this consistently will the safe management of skin pressure care.

Having a registered manager is condition of the providers registration. There had been no registered manager at Baylham Care Centre since December 2020.

We received positive feedback from people and their relatives about the caring nature of staff. People were treated with kindness. We received mixed feedback about the staffing levels and have recommended that the provider monitors the staffing levels closely.

We were assured by the infection prevention and control measures that were in place. Medicines were well managed.

Staff had received safeguarding training and were aware of their responsibility to report safeguarding concerns.

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.

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 (published 30 March 2021) and there were multiple breaches of regulation. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 30 March 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

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 COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Baylham Care Centre is a care home with nursing. At the time of our inspection 47 people were being provided with care and support which included younger adults and older people, some of whom have complex mental health and physical needs. The service can support up to 55 people.

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

We found significant concerns around how the service was managed particularly with regards to health and safety and risk management.

Risks to people's health, safety and welfare were not managed effectively, placing them at significant risk. People's care records were not always person centred and accurate. They lacked information to guide staff in how to meet their needs safely and effectively

People were not consistently supported to have maximum choice and control of their lives and staff did not support them in the least restrictive ways possible and in their best interests; the policies and systems in the service did not support this practice.

We received mixed feedback about staffing. People who were in receipt of 1:1 care were consistently supported by agency staff who were, at times unfamiliar to them. Staff training was not up to date. There were gaps in the skills and knowledge of staff across multiple areas of the service. Training in supporting people with complex needs and behaviours that may challenge was insufficient.

The home was not well managed, and the provider lacked oversight of quality standards and the care that was being delivered. Audits were not effective and had not identified the issues found during the inspection. A member of staff told us, “In the past everyone had worked very hard for the home to achieve an outstanding rating and it only took a short period of time to ruin that hard work.”

We observed many people to be happy living at Baylham Care Centre, supported by caring staff. People and their relatives did not express any significant concerns regarding the service. Many relatives also acknowledged, however, they had also had minimal time within the service in the past year due to the COVID-19 pandemic.

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

This service was registered with us on 9 September 2019 and this is the first ‘ratings’ inspection.

The last rating for the service under the previous provider was Outstanding published on 26 October 2017.

Why we inspected

The inspection was prompted in part due to concerns received about the management of risk and people’s safety. A decision was made for us to inspect and examine those risks.

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 coronavirus and other infection outbreaks effectively.

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.

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 breaches in relation to safe care and treatment, safeguarding, need for consent, staffing, good governance and notifications.

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 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.

Special Measures:

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 to varying the conditions the 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.

Baylham Care Centre is a care home with nursing. At the time of our inspection 47 people were being provided with care and support which included younger adults and older people, some of whom have complex health needs. The service can support up to 55 people.

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

Risk assessments were in place, providing guidance for staff in how to reduce risks and action they needed to take.

A system was in place to oversee any accidents or incidents that occurred in the service with the registered manager or deputy manager maintaining oversight and leading on any lessons learned.

Additional infection control measures had been taken in response to the COVID-19 pandemic, on occasion when staff were not wearing PPE in line with Government guidance, the registered manager took action to address this.

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 the service (under the previous provider) was Outstanding, published on 26 October 2017.

Why we inspected

This targeted inspection was prompted by a specific concern received about a person at the service after a fall from height. This incident is subject to a further separate investigation. The information CQC received about the incident indicated concerns about the security of internal doors in the prevention of falls from height and on the stairs. This inspection examined those risks.

CQC have introduced targeted inspections to follow up on Warning Notices or 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.

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 coronavirus and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.