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 inspection we rated this key question Inadequate. At this assessment the rating has changed to Requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was still in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed safely at the service.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service leaders were working to improve the culture of learning in the service but there were several areas where the service still needed to improve as evidenced in this report.

Staff understood their responsibilities to record and report any accidents or incidents. We found improvements since our last inspection and the manager had implemented systems to ensure accidents and incidents were regularly analysed to identify any emerging themes or patterns to mitigate further risks and improve the care provided. Following our inspection visit the provider told us any lessons learned are shared with their team during weekly clinical risk meetings and team meetings.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We found that pathways and transition processes were generally well established and supported people’s safety. Staff worked closely with external professionals, including GPs and community health services, to share relevant information and coordinate care. Overall communication was effective, particularly at the point of admission, which helped ensure people’s needs, risks and ongoing care requirements were appropriately managed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Improvements had been made since the last inspection and the manager shared concerns quickly and appropriately. The manager was aware of the local authority thresholds for reporting safeguarding concerns and how to report to these as required for investigation.

Relatives described how they felt their family members were safe at Baylham Care Home. They told us staff were vigilant, responsive and knew people well, which helped reduce risks and provided reassurance to families. One relative said, “I do feel [family member] is safe. The staff are very watchful especially of the ones who walk about as my [family member] does.” Another relative commented, “I feel [family member] is safe, it is a feeling, [family member] seems relaxed and likes walking the corridors.”

Staff had completed safeguarding training and understood how to report concerns about abuse or neglect. This included raising concerns within the service and, if needed, externally to relevant stakeholders. A staff member said, “Safeguarding is to respond and report appropriately make sure that all steps are taken immediately.”

The provider did not always work effectively with people to understand and manage risks in a way that kept them safe while supporting their independence and choices. Although risk assessments were in place for people, these were not consistently accurate, person‑centred or sufficiently detailed to guide staff practice. This meant people were not always actively involved in decisions about risk, and staff did not always have clear or reliable information to support them to provide safe and appropriate care.

We found examples where risk assessments contained contradictory information which created potential risks to people’s safety. For example, one person’s choking risk assessment stated they could use a lidded beaker, which directly conflicted with speech and language therapy advice recommending the use of an open cup with no lid or spout. In other cases, assessments identified a high level of risk but did not clearly describe how the risk presented or provided practical guidance for staff on how to respond.

Records relating to food and fluid intake were not always completed consistently, particularly for people identified as being at risk of weight loss, dehydration or malnutrition. Gaps in monitoring records meant there was limited assurance that people were receiving adequate nutrition and hydration, or that risks were being reviewed and managed effectively in partnership with them. Where people made choices that involved known risks, these were not always clearly explored, recorded or supported in line with best‑interest decision‑making or positive risk‑taking principles.

Improvements had been made to the call bell system that meant people had a reliable means of calling for staff assistance should they need it.

Risk management tools were in place, such as a clinical risk register, however this had not been effective in identifying these concerns. The manager was aware of the further improvements that were needed to develop the service and was taking a proactive approach to strengthen risk management and mitigation. The manager was aware of the further improvements that were needed to develop the service and was taking a proactive approach to strengthen risk management and mitigation.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

At our last inspection we identified areas of the internal environment that needed redecoration and refurbishment. We found at that inspection that furniture was worn and in a poor state of repair. Despite assurances provided after the last inspection that previously identified environmental concerns would be fully addressed, not all issues had been resolved when we returned for this inspection. Some areas still required further attention to ensure the environment consistently supported safe and high‑quality care. Many windows were found to be excessively dirty. This reduced transparency and obstructed natural light, preventing people from fully enjoying views of the external environment. The condition also detracted from the overall appearance and quality of the internal spaces.

However, we also saw that the provider had taken steps to implement positive changes, including improvements underway on the top floor environment and early signs of more proactive oversight. Following our inspection visit the provider sent us photographs of improvements they were making such as to the outside garden space. These developments demonstrated progress, though further work was still needed.

The provider did not always ensure there were sufficient deployment of qualified, skilled and experienced staff to meet people’s needs. There were also inconsistencies in how staff were supported through supervision, development and effective team working.

Feedback about staffing levels and deployment was mixed across people using the service, their relatives and staff. Some relatives raised concerns about staffing levels, particularly at weekends, and the impact this had on their family members. One relative commented, “Having not visited during the week I can only say that it seems to be only a skeleton staff at weekends.”

We also received mixed feedback from staff. Some staff expressed concerns that staffing levels were not always adequate to enable them to respond to people in a timely way, resulting in delays to care. One staff member told us, “We are told that staffing is now based around needs rather than the number of [people], however I still feel that the middle floor does not have enough staff to meet needs in a timely manner. Some [people] choose to stay in bed until the afternoon, which is fine, but some would like to get up earlier and staff can't get to them quick enough. Some [people] aren't out of bed until 11.30am-midday… and it also means staff miss out on breaks etc.” This highlighted ongoing pressures on staff and the impact this could have on both people’s experience of care and staff wellbeing.

Other staff were more positive and felt there were sufficient staff to keep people safe. One staff member said, “Yes, there are sufficient staff on duty to meet [people’s] needs promptly. For example, call bells are answered quickly, support is available during personal care, and [people] receive timely assistance with meals, mobility, and medication. Previously, the service depended on agency staff but with the new management they have employed staff and give training every month…the service is no more depending on agency unlike before.” One staff member said, “There have been an influx of new [people admitted], and some unreliable staffing ranging from no shows to sickness causing issues with staff shortages. I know all the staff there work really hard and to the best of their abilities when facing such pressures from time to time. I would like to see less agency being used, so that [people] get to know the staff caring for them.”

Staff told us they had access to the training they needed to meet people’s needs and support them safely, and that this had improved over time. One staff member commented, “I believe the amount of training we receive has definitely improved since a year ago, we are offered more training opportunities, and I think management are more on top of staff getting their eLearning done as well. I think dementia care training could be better/could have more but I think these opportunities are coming up in the near future.” This demonstrated progress, although further development was still needed.

During the inspection, we observed that staff were visible throughout the service; interactions with people were generally positive however they were often task-focused, and staff appeared busy. This meant we were not assured that staff were always effectively deployed to ensure people’s needs were met promptly and in line with their preferences.

The provider had appropriate safer recruitment processes in place. People were supported by staff who had been recruited safely, and pre‑employment checks included obtaining references and Disclosure and Barring Service (DBS) checks. These checks help employers make safer recruitment decisions and reduce the risk of unsuitable people working in care services.

The provider did not consistently assess or manage risks relating to infection prevention and control. Systems to identify, monitor and reduce the risk of infection were not always effective, and there was limited assurance that risks were promptly detected, controlled or escalated to relevant agencies when required.

At our previous inspection, we found areas of the service were visibly dirty, increasing the risk of bacteria build‑up and cross‑contamination. Although the provider had given assurances that these concerns would be addressed, at this inspection we found that planned improvement works were still incomplete. While refurbishment and remedial works had commenced on the third floor, similar standards had not yet been achieved across the rest of the service, and further action was required to ensure the whole environment consistently supported safe, hygienic care.

The manager told us there were no financial restrictions preventing the completion of the required works and that environmental improvements formed part of the service’s ongoing improvement plan. However, at the time of this inspection, these actions had not yet been fully implemented, meaning people remained at risk of avoidable exposure to infection.

A sinks in the treatment room was not included in the maintenance audit for unused water outlets to minimise the risk of Legionnaires’ disease. As a result, there was an increased risk of Legionella bacteria developing due to stagnant water, which could lead to avoidable infection and serious illness for people using the service, staff and visitors. This was actioned immediately by the maintenance member of staff when we raised this concern

The provider did not always make sure that medicines and treatments were safe as medicines were not safely managed and systems to monitor medicines required significant improvement to ensure safe practice.

During the inspection visit we saw one person complained of chest pain. Appropriate action was not taken at the time to establish whether they required pain relief for angina in line with their care plan. Action was taken following our inspection to review this person, take observations and introduce a pain monitoring tool as part of their care plan.

We saw from records that eye drops, which were past their expiry date, had been administered to 2 people. This meant there was an increased risk of ineffective treatment, infection or harm, as expired medicines may not work as intended. We also saw one person had been given antibiotic eye drops for over 2 months; there was no care plan in place and no plan for review. The lack of a care plan and review also meant there was insufficient oversight to ensure the medicine remained appropriate for the person’s needs.

Thickener, which is used to make fluids safe to drink for some people, was stored in an accessible cupboard in the kitchenette area where vulnerable people could gain access. This presented a choking hazard and was not being stored in line with a national safety alert.

People who were having their medicines covertly (hidden in food or drink) had all the necessary information in place which showed us that decisions had been made in their best interests, however, details of how to administer the medicines appropriately was not always available on the electronic medicines administration record.

Some of the equipment used to administer medicine such as tablet crushers and masks and asthma aero chambers were not clean, and one was damaged so unable to be cleaned thoroughly. Parenteral syringes, rather than oral syringes, were being used to administer liquid oral medicines, this was not in line with a national safety alert. The manager and nurses took action to address these concerns immediately.

Documentation did not show that action had been taken when the medicines fridge stopped working, although staff did reassure us that they had acted appropriately at the time to move medicines requiring cold storage. No minimum and maximum temperature were being recorded so there was no record of the maximum temperature the fridge had reached before action was taken.

Medicines that were administered by a topical patch were always recorded but not always rotated appropriately, records indicated that they were applied sometimes in the same place when they should be applied on a different area of the body. Not all topical medicines such as creams or ointments had a date opening or clear expiry on them to ensure they continued to be suitable to use.

Care plans were in place for medicines, however there were no care plans for three people who had medicines prescribed for End of Life and one existing care plan was not person specific and did not include the correct medicines. Two of the medicines on the electronic system had the incorrect indications on the prescriptions and this was not in line with the authorisation form written by the prescriber. The electronic system had an inbuilt checking system that required two members of staff to input the medicine administration information. There was no advance care planning in place for one person, however the medicines used for EOL care had already been prescribed and were available to be administered.

Another care plan stated that for a person who may experience seizures, that staff were to administer a rescue medicine if the seizure lasted longer than 5 minutes. No rescue medicine was prescribed or available to give. This meant staff had no accurate guidance to follow in the event of a seizure, significantly increasing the risk of delayed or inappropriate response.

Staff were trained in medicines administration and had completed competency checks of their ability to administer medicines safely; however, we saw documentation where insulin had been documented as being given for incorrect reasons. This meant the provider could not be assured that insulin was always administered safely and in line with people’s prescribed care, increasing the risk of medicines errors and avoidable harm.

We saw people were treated with care and dignity, and we saw staff frequently took a non-drug approach to supporting people with behaviours that challenged using deescalation and distraction techniques as opposed to chemical. Records indicated that medication was only used as a last resort to control behaviour.

Medicines administration was being recorded on an electronic medicine administration system and there were no gaps in recording which meant people were receiving their medicines. People’s allergies were clearly documented.