Bay Tree House

Bay Tree House is a residential care home providing personal care and accommodation to up to 16 people. The service provides support to older people living with dementia. At the time of our inspection there were 15 people using the service. The home is an adapted period building with accommodation over two floors serviced by a lift.

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

We could not be assured that medicines management was consistently safe and followed good practice. This meant the arrangements currently in place risked error. The quality monitoring governance system in place had failed to identify these concerns.

People were practically 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. However, records did not evidence this approach as required by the MCA. We have therefore made a recommendation regarding adherence to the Mental Capacity Act 2005 (MCA).

Whilst people received dedicated and person-centred care that they had control over, the associated care plans did not reflect formal involvement either by those people that used the service or those people who held legal authority to make decisions on their behalf. The relatives we spoke with told us they wanted this.

The service communicated well with people and their relatives however there were no formal systems in place to seek their feedback such as via meetings or surveys for example. However, relatives told us they were happy with the service provided and had no concerns.

Staff were dedicated, committed and caring however there were concerns there were not always enough staff to manage an emergency event, such as a fire, should it occur. Staff and relatives told us staff were pressured but that it did not impact on the level of service provided. Staff were mostly safely recruited however the provider needs to ensure processes are consistent in seeking assurances about suitability of staff.

People’s nutritional and healthcare needs were met, and we found robust infection and prevention measures in place. For example, the home was consistently clean throughout and the risk of COVID-19 had been assessed and well managed.

Management were supportive and people told us they had confidence in them. Staff worked well together, and the culture was positive, open and nurturing. The provider placed emphasis on training, and this had resulted in staff that demonstrated the right values and skills to care and support the people who lived at Bay Tree House. All the relatives we spoke with told us they would recommend the home.

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

This service was registered with us on 06 November 2020 and this is the first inspection.

Why we inspected

We inspected this service due to it being a newly registered service.

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.

Enforcement and Recommendations

We have identified breaches in relation to medicines management and governance at this inspection.

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 monitor the service and will take further action if needed.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.