Baylham Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a challenging, defensive culture within the service which the provider acknowledged and told us they were in the process of a major staff culture and quality overhaul. We found, however, there was resistance by the provider to accept evidence and feedback received as part of this inspection. Despite being given additional time to evidence systems were in place to provide people with a safe service, a care plan/risk assessment completed after feedback and sent to us by the provider was of a poor, unprofessional standard. For example, the provider used an outdated reference to people who used a wheelchair to mobilise and considered being able to 'yell' for assistance was safe and sufficient to replace the lack of working call bell system.

We had raised concerns with the provider about safeguarding incidents for which the provider should have notified us, as required by regulation. The provider sent us and confirmed they were following the local authority guidance for the thresholds in reporting safeguarding concern to the local authority safeguarding team, but this did not demonstrate they understood their roles and regulatory responsibilities to notify CQC. The regulation specifies a range of events or occurrences that must be notified to CQC so that, where needed, CQC can take follow-up action to monitor what lessons have been learnt to reduce future risks. Not informing CQC of incidents risks contributed towards a closed culture where information was not being shared openly.

The service was not consistently well led, and we found significant concerns during our inspection, however, there was also a whole new management team in place and some staff and relatives spoke of a hope things would now start to improve. One staff member told us, “The current management we have are very good… they understand there is a lot going on but fully support the team in all departments. We haven't felt this for quite a while.”

The management team told us they were aware of actions needed to improve the quality of the service.

The service lacked an open and transparent culture. Safeguarding concerns were not always reported or identified by the provider, and they could not demonstrate how people, and their relatives would be informed of these promptly.

People, relatives and staff did not always feel they could speak up and that their voice would be heard, however we recognised the service was also going through a significant transition with a change of management team. A relative told us, “The management were approachable but at present they are appointing a new management team, so things appear to be a little fraught. Communication has been a problem since they lost their ‘front of office’ person.” Another relative said, “I do find that communication is not very good they have a relative meeting once a month, but unless you know where to look for times you wouldn’t know.” A third relative said, “With my experience so far with Baylham I would be hesitant to recommend, I am hoping that future changes in management are going to create a far more effective environment for all concerned.”

We also received mixed feedback from staff about the processes in place to support safe speaking up in the workplace. One staff member told us, “Staff are supported by each other. Management is not always supportive or we’re not always able to gain access to even speak to them as they have door shut and when we knock on the door and keep going back there is no answer.” Another staff member said, “We [staff] had a large mandatory meeting where management called and shouted at their staff, saying they were incompetent and thieves. At the meeting, some concerns were raised, such as the lack of staff on ‘the floor’ at night. 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.” Other staff were more positive. We were also told, “Morale is picking up and positive vibes are beginning to emanate around the home. Adjustments to changes of management and direction all take time but I feel they are doing a tremendous job.”

Whilst the provider recruited a diverse workforce from a variety of backgrounds, some staff told us they were not always included in the service and didn’t feel supported. However, other staff told us they felt supported in their role and worked well together as a team. One staff member told us, “Morale is picking up and positive vibes are beginning to emanate around the home. Adjustments to changes of management and direction all take time but I feel they are doing a tremendous job.” Another staff member said, “We have plenty of training though I feel it would be good to have more in-depth dementia training for working those with people that have greater (anxiety and distress] issues and requirements.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. There has been a history of non-compliance with regulations and breaches of regulation, and poor ratings. In the two inspections since registration, one was rated inadequate, and one requires improvement. Improvements noted at the last inspection had not been sustained. We found management systems had not been effective in identifying shortfalls in the quality and safety of the service. Whilst the provider told us they were now aware , they had not taken the necessary actions to address themleading to a significant deterioration in the service provided, which demonstrated lessons were not always learned, timely action taken and where improvements had been noted at our last inspection, these had not been sustained.

There were multiple concerns across the different quality statements at this inspection. For example, a failure to recognise the need to notify CQC of safeguarding incidents that caused harm to people and a failure to safely manage risks to people. Audits of medicine administration were not effective. Errors had not been recorded as incidents or analysed to prevent further incidents. A monthly audit did not provide enough detail to give assurance.

The provider did not always demonstrate good oversight of the service. Systems for monitoring incidents and accidents were not robust.Fire safety checks had not identified a failure to update staff knowledge and skills with regular fire drills.

Systems to support the deployment of staff were not effective. The provider told us they assessed the personal care needs of people to determine how many staff were required and where they should be deployed across the service. This did not take account of changes in people’s needs, including dementia, mental health or mobility. Records were not always accurate, complete and contemporaneous. Some records were handwritten and were difficult to read or illegible. Daily records had gaps where no information was recorded, sometimes for several days.

People’s relatives feedback included a lack of involvement with care planning; many told us they had not been asked formally for feedback on the service.

Systems for monitoring incidents were not robust. Altercations between people with dementia were not always reported to the local authority or to CQC in line with safeguarding procedures. This did not support openness and transparency or ensure the provider took the opportunity to demonstrate what proactive actions were being taken to minimise risks and support people’s quality of life at the service? .

The management team told us that they were working with the local authority safeguarding team to implement improvements and an improvement plan for the service was in place. However, these improvements were ongoing and were not fully embedded at the service at the time of our inspection.

The provider’s systems failed to identify shortfalls and support learning to make improvements. Incident records were not always accurate and complete, there was a lack of analysis to identify patterns and trends and to learn from mistakes.

Accident and incidents were not thoroughly investigated to ensure learning for the service, or other services where they may have been identified in the incident. Actions taken by the service lacked analysis so these could not be shared in team meetings with staff for them to embed learning and improve care outcomes for people.

The management team were unable to demonstrate where learning had taken place and been used to make improvements to the service. They had continuously failed to maintain oversight, learn lessons and make changes to improve people’s experiences.