CQC report explained · a nursing home
What the CQC found at Badby Park
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, January 2024
Rated Requires Improvement; inspectors found safe, kind and responsive care, but problems with the environment, staff culture and leadership.
This was an unannounced inspection in September 2023. Inspectors spoke with 11 people living in the home, 10 relatives and 12 staff. They reviewed care records, medicines records, complaints, training and management information.
The home was rated Good for Safe, Caring and Responsive. People were protected from abuse and avoidable harm, medicines were managed safely, and staffing and recruitment checks were suitable. People described staff as kind and were supported with personalised care, activities and contact with families.
The home was rated Requires Improvement for Effective and Well-led. One living area was unsuitable, some outdoor spaces were difficult or unsafe for wheelchair users, and staff teams did not always work well together. The home was rated Requires Improvement overall and has had this rating for four consecutive inspections.
Risk management
Known risks were assessed and staff had care plans to follow. Safeguarding systems, medicines, staffing and infection control were also found to be safe.
“People were protected from risks as these had been assessed and staff had care plans to follow to mitigate known risks.” from the report
Kind and respectful care
People and relatives gave positive feedback about staff. Inspectors saw people treated with dignity and supported to make choices.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised support
Care plans included people's needs, preferences, likes and dislikes. People could take part in activities and outings and stay in touch with family and friends.
“People were supported as individuals, in line with their needs and preferences.” from the report
Clinical oversight
The provider had improved its clinical systems. Inspectors found these improvements had become established, with clear oversight of safety in this part of the service.
“The provider had made improvements to the clinical systems. These had been embedded and the provider had clear oversight of the safety of this part of the service.” from the report
Unsuitable living area
needs fixingAn area where five people lived had a small lounge that was also a walkway. People could not freely leave the area or access other parts of the building without staff help.
“An area of the building in which 5 people lived was not fit for purpose.” from the report
Poor outdoor areas
needs fixingSome gardens were not well maintained and were unsuitable for wheelchair use. Inspectors found there was no clear timescale for all planned outdoor improvements.
“This garden area is really difficult to push a wheelchair in due to the uneven slabs.” from the report
Staff culture and teamwork
needs fixingInspectors found poor communication, blame and poor attitudes between some staff teams. Some staff did not feel able to raise concerns safely or confidentially.
“We observed poor staff attitudes, communication breakdown and a blame culture.” from the report
Weak management oversight
seriousThe provider had not used effective systems to monitor and improve quality and safety consistently. This led to a breach of Regulation 17.
“The provider had failed to operate effective systems and processes and provide consistent and effective leadership to assess, monitor and improve the quality and safety of the services provided.” from the report
- 01What has changed in the living area for the five people, and when will the planned recommissioning be completed?
- 02What specific work has been done to make the gardens safe and suitable for wheelchair users, and what are the completion dates?
- 03How are you measuring whether communication, teamwork and staff morale have improved?
- 04How can staff raise concerns confidentially, and what protection is available if they do so?
- 05What actions are included in the Regulation 17 action plan, and how will families be told about progress?
This was an unannounced inspection covering all five CQC questions, with particular attention to concerns about staff culture, the environment and management oversight. This explanation was written from the published report of 9 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2022
Badby Park was rated Requires Improvement; inspectors found kind, person-centred care and better systems, but safety and leadership were not yet consistent.
This was an unannounced follow-up inspection on 18 November 2021. One inspector, a specialist nurse adviser and an Expert by Experience visited the home. They spoke with seven people, three relatives and eight staff, and reviewed care, medicines, training, complaints and management records.
People were generally protected from abuse and received their medicines as prescribed. Infection control arrangements were followed and there were enough staff. However, some risk information and emergency records were not always kept up to date consistently. Inspectors said safety systems needed more time to become reliable.
Care was rated Good in the effective, caring and responsive areas. People received personalised care, kind support, suitable food and help to take part in activities. The home’s overall rating was Requires Improvement because Safe and Well-led were both rated Requires Improvement.
The home had improved since the previous inspection and was no longer in breach of regulations. The provider still needed to show that these improvements could be sustained. CQC said it would continue monitoring the home until its next visit.
Personalised support
Care plans included people's health needs, preferences and life history. Staff knew how people wanted to be supported and records reflected changing needs.
“Care plans included detailed information about people's needs and preferences.” from the report
Food and healthcare support
People received help to eat and drink, including support with feeding tubes when needed. Weight was monitored and referrals were made to specialists where required.
“People were supported to eat and drink a balanced diet. Where people needed support to eat and drink this was provided.” from the report
Safety records needed to be more consistent
needs fixingRisk assessments and emergency grab sheets had been updated, but inspectors said this was not yet consistently applied. This meant there was still limited assurance that safety information would always be current.
“Keeping information updated on risk assessments required embedding and needed to be consistently applied to ensure the systems and processes in place were effective.” from the report
Leadership was not yet consistent
needs fixingThe home had improved its monitoring systems, but inspectors still rated leadership Requires Improvement. They said the management and leadership approach did not always support high-quality care.
“This meant the service management and leadership was inconsistent.” from the report
Some concerns were not felt to be heard
minorMost people and relatives felt confident raising complaints, but some did not feel their concerns had been listened to.
“Not everyone felt their complaints or concerns were listened to.” from the report
- 01How do you now make sure risk assessments and emergency grab sheets are updated whenever a person's needs change?
- 02What checks show that the improvements to quality monitoring are being applied consistently across all three units?
- 03How are complaints and informal concerns recorded, investigated and fed back to people and relatives?
- 04How do you make sure there are enough suitably skilled staff on every shift, including when agency staff are used?
- 05What support is available for people who are waiting to move to more independent accommodation?
This was an unannounced follow-up inspection after the previous rating of Requires Improvement, with infection prevention and control specifically checked under Safe; it was not described as a new comprehensive inspection. This explanation was written from the published report of 14 May 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Badby Park
7 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- January 2024Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- January 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 30 August 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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