Baylham Care Home

On this page

• 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 inspection we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in a continued breach of legal regulation in relation to governance at the service.

This service scored 54 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

A cultural shift was underway Baylham Care Home following a change in the local and wider leadership and management team. Prior to these changes, there was a lack of shared direction and a culture that had not been consistently underpinned by effective leadership oversight. This had contributed to variable practice across the service and limited confidence that concerns or risks would be identified and addressed in a timely way.

With the appointment of a new manager and senior leadership changes, there were early signs that the service was starting to move in a more positive direction. Some staff described a noticeable shift, with clearer expectations, increased management visibility and the introduction of more structured monitoring arrangements. The manager reflected an intent to strengthen accountability and improve standards of care. However, the culture remained challenging in parts, and not all staff felt fully engaged or aligned with the new direction, particularly given the pace of change and the service’s recent management changes.

Although these improvements were still in their infancy and further work was required to embed a shared vision, build trust and consistency. Sustained focus was needed to ensure staff felt supported, involved and confident in the direction of travel, and that governance arrangements were robust enough to support continuous improvement across the service. A staff member told us, Baylham will rise again because we want it and are working towards it.Not everything is perfect but it's not for the want of trying.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The new manager recognised that improvements were needed at the service, particularly in relation to the effectiveness of management oversight, which had not previously, at our last inspection, been robust enough to ensure safe and consistent practice. Since the appointment of a new manager, there had been a noticeable shift in approach, with early signs of improved leadership, clearer expectations and better monitoring systems beginning to take shape. While some staff recognised the need for firmer leadership following previous instability, others found the approach difficult to adapt to and described concerns about how changes were being implemented.

The manager and wider leadership team had only been in post for approximately 3 months at the time of this inspection. During this period, the manager had identified the significant improvements needed across the service. An action plan was in place and early steps had been taken to strengthen monitoring systems, improve staff deployment and address previously identified risks. These changes demonstrated that the manager understood the challenges within the service and was taking responsibility for driving improvement.

Some relatives described seeing increased managerial presence within the service with leaders spending more time on the floors, observing practice and setting clearer expectations around safe care delivery. One staff member told us, “Our manager is actively walking round, observing staff on floors, ensuring staff are where they should be and putting into place measures that are required to keep residents safe. [Manager] is trying to improve staff communication between departments and provide a more motivated approach, so staff take responsibility seriously. And has been firm when needed with staff, in outlining their expectations for how [people] should be cared for.” Another staff member commented, “Management do come out into the floors to supervise some things and will guide where needed to those who need it however could be a bit nicer sometimes with the guidance and give proper explanations…”

We received mixed feedback about freedom to speak up. Several relatives told us the manager had an ‘open door’ approach and there was confidence the service would improve. However, staff did not always feel they could speak up and that their voices would be heard with several telling us they did not feel safe or confident to voice concerns and described a fear of negative consequences or retaliation if they spoke up. This included worries about how concerns would be received and whether raising issues might impact their working relationships or how they were treated at work. These concerns were compounded by recent leadership changes, which had created a period of uncertainty and transition. As a result, not all staff felt fully supported or safe to raise concerns, which limited openness, trust and transparency across the service and reduced opportunities for shared learning and improvement. One staff member said, “Due to fear of retaliation, there is no safe internal way to raise these concerns, as staff believe their jobs may be at risk.”

Policies to support speaking up, including whistleblowing procedures, were in place and staff were aware of them. Further work was needed to ensure these processes were consistently embedded in practice and that staff felt safe, supported and reassured that concerns could be raised without fear of reprisal. While a more structured and directive leadership approach was being introduced, some staff told us they were struggling to adapt to the new style and expectations. Following our inspection visits the provider told us staff were supported to speak up through their whistleblowing policy and also HR surgeries that had been held.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Many staff described the period leading up to the inspection as difficult and challenging due to previous management style and current management changes. Several staff told us they did not consistently feel respected in their roles or that their views were listened to or acted upon. This had contributed to low morale for some staff and had, at times, affected working relationships and trust within teams. Some staff felt disengaged from decision‑making processes and were unclear about how their feedback influenced change, which limited their confidence that issues would be addressed promptly or fairly.

The manager acknowledged these concerns and was in the process of implementing significant changes to address longstanding issues. The manager was required to make several difficult and sometimes unpopular decisions to improve safety, quality and oversight, while also working to promote fairness and equality across the workforce.

The provider did not always have clear or effective systems of accountability and governance. As a result, they did not consistently act on the most relevant and timely information about risk, performance and outcomes, nor were they always able to demonstrate that information was escalated, shared or acted upon appropriately when required. This limited the provider’s ability to identify concerns early, assure itself of the quality and safety of care being delivered, and drive sustained improvement across the service.Governance processes were in place to monitor the quality and safety of the service; however, these arrangements were not consistently effective in identifying or addressing the issues we found during the inspection. For example, there were systems and processes to oversee quality and safety, but these had not yet fully addressed all of the concerns identified at the last inspection. This indicated that governance systems had not been robust enough to ensure that required actions were completed, embedded and reviewed to provide assurance of sustained improvement over time.

However, the new manager, who had only been in post 3 months at the time of this inspection, was working alone, without a clinical lead or deputy post in place. This increased the manager’s workload and reduced the capacity for effective clinical and operational oversight, making governance more challenging and limiting opportunities for shared leadership, challenge and support. The manager was working to an action plan and was aware of the improvements still needed. They demonstrated an understanding of the risks and challenges within the service, alongside an acknowledgement that further work was required to strengthen oversight and governance arrangements.

Leaders and the staff team understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Referrals had been made to external health and social care professionals when specialist services and guidance was required to promote people’s well-being to ensure people’s healthcare needs were being met and reviewed. This included GPs, social workers and speech and language therapy.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Quality assurance and auditing arrangements were in place; however, these systems had not always been effective in identifying risks, addressing concerns or driving timely improvement. As a result, some issues identified during the inspection had not been recognised or resolved through existing monitoring processes such as the concerns found with the safe management of medicines. Although audits and checks were completed, they did not consistently provide leaders and managers with sufficient oversight, assurance or evidence that required actions were implemented, embedded and leading to measurable improvements in people’s care and outcomes.

Staff told us they did not always feel that their views, feedback or concerns resulted in meaningful change. This reduced staff engagement in improvement activity and limited opportunities for shared learning and collective problem‑solving across the service.