Baylham Care Home

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 requires improvement. 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 people’s safe care and treatment, safeguarding and premises and equipment.

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.

Lessons were not consistently learnt to continually identify and embed good practice and systems for monitoring people’s safety were not robust. Although the provider had systems and processes for recording accidents and incidents, there was a lack of safe and appropriate reviews to learn from and prevent re-occurrences.For example, there were repeated incidents of violence and aggression between residents, no analysis was undertaken to understand could these incidents have been prevented and what could have been put in place to reduce the risk of reoccurrence.

The provider did not always maintain safe systems of care, they did not always manage or monitor people’s safety.

At the time of our inspection visits the provider was in the process of updating care plans and moving to a new care planning system as they had recognised significant shortfalls and that improvements were needed. However, at the time of our inspection, the provider did not have fully effective systems to review and make changes to care plans when people’s needs changed. This meant that staff did not always have the information they needed to provide safe and effective care.

The provider did not protect people’s right to live in safety, free from harassment and abuse. The provider did not share concerns quickly and appropriately. Staff, including the registered manager failed to consistently identify and report abuse when providing care and treatment.

Systems for safeguarding people were not robust.Records included evidence of altercations between people which had resulted in significant verbal abuse and physical harm. Not all of these events had been considered by the provider as safeguarding incidents. This meant safeguarding alerts had not been raised with the local authority and the required notifications to the Care Quality Commission were not submitted. We raised this with the provider who sent us a copy of their safeguarding tracker, which did not contain all safeguarding incidents that had

occurred as well as the local authority safeguarding policy. This demonstrated a lack of understanding into their regulatory responsibilities to keep people safe.

We received mixed feedback from people and their relatives regarding whether they felt safe living at Baylham Care Centre or not. Where they were concerned, this was attributed to unexplained accidents and incidents occurring which made them worry. The local authority had an organisational safeguarding enquiry ongoing at the time of our inspection due to concerns about people’s safety at the home. They had made the decision to not place any service users into the service until improvements had been made.

Just before, and during the inspection, we received 12 whistle blowing concerns from staff about people’s safety at Baylham Care Centre. We raised these with the local authority safeguarding team where appropriate and also requested the provider took action to investigate each concern. The provider told us they believed not all the concerns raised had been made in good faith.

The provider did not consistently work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe. A relative told us, “I can't say hand on heart that [family member] is safe at Baylham, [person] an aversion to [some] staff and does not respond to them well resulting in aggressive behaviour towards them which doesn't bode well for good relationships for both parties.”

Recording of incidents was inconsistent, and there was a failure to investigate and learn lessons to improve safety. We noted multiple accidents and incidents, including physical and sexual altercations between people. These were recorded in daily records but had not been consistently escalated as safeguarding incidents. There was variable quality in the records of what actions had been taken to evaluate these incidents, including escalating as safeguarding concerns to the local authority. This did not give assurance that all incidents were reported internally and externally, or that appropriate actions had been taken to identify safeguarding concerns and prevent further occurrences.

People did not always have access to call bells, or a reliable means of calling for assistance, in their bedrooms due to a fault with the call bell system. The provider told us they were aware of the fault and already had plans in place to replace the system, which was fully replaced during the inspection time frame. Relatives and staff told us there had been concerns with the call bell system not working reliably for a long time. We found, despite the provider, being aware of the concerns with the call bell system, individual risk assessments had not been completed for allpeople affected, meaning risks associated with them being unable to summon assistance from staff had not been considered for all those affected.

Systems to monitor risks to people’s health and welfare were not joined up. For example, where people were at risk of constipation, records of bowel movements were not consistently stored in one place to enable effective oversight to make any concerns easily identifiable and so that staff could seek medical assistance where required. We were also not assured by staff responses. One nurse told us that the system for bowel monitoring was to check people’s abdomen to see it was soft. Following our inspection the provider told us, there were inconsistencies in documentation rather than a lack of oversight. However, further work was needed to ensure records were maintained of management oversight and actions taken in response to shortfalls identified.

Not all staff were aware of the action they needed to take in the event of the fire alarm sounding. We spoke to several staff, including those in charge of a shift responsible for guiding staff in the event of the fire bell sounding, who were unable to tell us the fire safety procedure they needed to follow. This meant there was a risk staff would not take the correct action in the event of a fire emergency. In response to our feedback the provider told us they had followed this up with staff, and where necessary, provided further training on the correct fire safety procedures.

The provider did not always detect and control potential risks in the care environment. The premises were not consistently maintained to a high standard, and environmental risks were not adequately identified or managed.

The environment was not always safe. For example, a room containing medical equipment, scissors and a quantity of alcohol had been left unsecured. In one person’s bedroom we found unsecured diabetic testing lancets for blood tests. In another room unsecured razors. These placed people living with dementia at risk of harm should they have accessed them inadvertently. Following our inspection visit, the provider told us it was appropriate for people to have razors in their bedrooms, however, no individual risk assessments were provided. They also told us they had secured the unlocked room and removed the lancets.

Areas of the internal environment were in need of redecoration and refurbishment. Furniture was worn, in a poor state of repair, meaning it could not be effectively cleaned, and some equipment was dirty for example, there were some bedrooms that required painting and some and fixtures were worn such as en suite bathrooms and equipment, bedroom furniture and the kitchen area in the ‘attic’. One staff said, “The garden could be tidier, improving residents' well-being considerably. A pampering room for them, a decent smoking area, parking spaces, and improved call bells are also needed.” Following our inspection visit the provider told us that extensive redecoration had been carried out throughout the home; however, some staff told us they felt further improvements were needed. We saw people had been supported to personalise their bedrooms.

Prior to our inspection we received concerns about the staffing levels and the visibility of staff. We observed a visiting relative intervening when a physical situation between two people began to escalate and there were no staff in the vicinity. This placed the relative and people at risk of harm. Another relative told us, “Baylham are very short staffed. They are busy recruiting but recently agency staff have gone, and I feel although agency staff are not ideal, they are better than being so short staffed at least till new staff are recruited.” Another relative commented, “Staffing levels are always pretty lean at weekends.”A third relative commented, “There are different staff every time I visit.”

Many staff told us they felt there were not enough of them to provide person centred care to people. One staff member said, “At a meeting, some concerns were raised, such as the lack of staff on the floor at night during rounds (as most are doubled up). Management did not agree to any extra staff, calling the staff "lazy." Also, after the mandatory meeting, many staff members asked if they would be paid for the meeting, and management told us no, because they didn't want to.” Another staff member told us, “I feel some days we struggle with certain staff we currently have 5 staff on middle floor I know numbers go by how many residents, but this does not take into account the current needs of those we care for.” A third staff member commented, “We have a lot of agency [staff] at the home and also not enough staff on the floors. On the Attic we have two staff in morning and then one in the afternoon. They expect us to take the 1:1 staff away from a person who has that support to help other people who need more than one staff or to work [unsafely] alone.”

We found there was not always sufficient staff deployed to meet people’s needs in a timely manner. For example, several staff told us the staffing arrangements on the upper floor at night were two staff, one staff member specifically providing 1:1 care to a person and the second staff member to meet other people’s needs. We were told that the one staff member providing 1:1 care was left alone with all people living on the upper floor for a period of time. This was because the second member of staff on duty had kitchen tasks to complete during the evening. A service user also confirmed this by telling us, “At 10pm the carer goes down to clean the kitchen. That just leaves one staff member who is with another person on a 1:1 basis. They can’t leave that person even if I’m choking or vomiting, I’d had have a long wait. I ask them just to pop their head in to check everything is okay, how are they treating the [people] who can’t speak out.” Following our inspection, the provider told us that staff had walkie-talkies to obtain assistance, however, these were only introduced during the second day of our inspection and once concerns about the staffing levels had been raised.

We were not assured people were supported by staff who had the appropriate training and skills. Training records showed some gaps in staff training. We also had concerns raised by multiple staff about the training received at the point of employment and induction. One staff member said, “I would suggest that Baylham needs to focus on training at the beginning and not allow anyone on ‘the floor’ without completed training, especially for new staff members.” Another staff member told us, “A few staff have been at Baylham for couple months and been working with no training apart from [conflict management] and manual handling.” A third staff member commented, “Baylham Care Centre is a challenging place to work from induction. No one will show a staff member a proper induction for example for enteral feeding training. Managers are not informative if you ask for help, they assume you know everything.” A fourth staff member said, “I have been expected to support people with a catheter and stoma and changes, but I have not received any training.” A lack of proper induction means staff could commence employment without the skills and experience to deliver safe and effective care.Following our inspection, the provider told us, “New staff shadow for at least three shifts and are supervised until competent, with access to eLearning modules and a mentor.”

There were areas of the home that were visibly dirty in places. A member of staff told us, “In terms of infection control we could do with some more housekeeping staff, just because we have more challenging residents now than we had before.” We observed some dirty areas of the care home such as carpets, crash mats and bathrooms. In 2 people’s ensuite bathrooms, we noted damp and rusty equipment. This increased the risks of bacteria accumulating and contamination, placing people at risk of infection.

However, we also noted good practice. There were hand washing stations and staff had access to personal protective equipment such as gloves and aprons. Staff told us that hand washing audits took place to ensure staff were washing their hands appropriately.

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.

Staff had been assessed as competent to give people their medicines, however, during the site visit we observed that staff did not always follow safe procedures when giving people their medicines. In addition, records showed that there had been errors with medicines including recent incorrect doses of insulin given to a person.

We found that topical medicines were not being stored securely in areas where people could access them and potentially cause themselves harm.

There were some gaps in records and the information available to staff to be able to manage people’s medicines safely such as for the safe application of medicated skin patches. We found that records showed staff had not appropriately varied the sites of application of the patches to reduce the risks of skin-irritant effects.

When people had their medicines prepared in their food or drinks (for covert administration), records did not confirm that staff authorising this had consulted with a pharmacist to ensure it was safe for people’s medicines to be prepared in this way. The views of their next of kin or advocate in reaching best interest decisions about this had also not been recorded.

Medicines were not managed safely. We found medicines that were no longer needed or that had belonged to people who had died were still at the service. They were stored in the medication room, the controlled drugs cabinet and the refrigerator. It is essential medicines are disposed of in accordance with guidance and regulations.

Best practice guidance was not followed for the use of transdermal patches. For example, the record of application did not include recording the specific location on the body where the patch had been applied. Continual use of the same area of application may cause irritation or skin breakdown.