CQC report explained · a residential care home
What the CQC found at Bay Tree House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not consistently stored, prepared or recorded safely. Inspectors also lacked full assurance that there were enough staff to keep people safe during an emergency.
- Effective?
- Requires improvement
- People's health, food and drink needs were met, and staff were well trained. However, records did not consistently show that decisions followed the Mental Capacity Act, and none of the applications to restrict people's liberty had been processed at the inspection.
- Caring?
- Good
- Staff treated people with kindness, patience, dignity and respect. People were offered choices during care, although formal involvement in care planning was not always recorded.
- Responsive?
- Requires improvement
- Care plans were person-centred and people's needs were met. However, relatives had not taken part in care plan reviews, and feedback about the amount of activities was mixed.
- Well-led?
- Requires improvement
- The culture was open, caring and supportive, but quality checks had not identified important medicines and record-keeping problems. The improvement plan did not cover all the changes needed.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found kind, person-centred care but serious medicines and management checks needed improvement.
This was the home's first inspection because it was newly registered. It was unannounced. Inspectors visited on 04 August 2022 and reviewed care records, medicines records, staff recruitment and training, quality checks and maintenance records. They also observed care, spoke with staff and relatives, and checked infection control.
The home was rated Requires Improvement overall. Safe, Effective, Responsive and Well-led were also rated Requires Improvement. Caring was rated Good. Inspectors found medicines were not managed consistently safely, and the home's checks had not found these problems.
People were treated kindly and received person-centred care. Their food, healthcare and infection control needs were met. However, care plans did not show enough involvement from relatives, activities were not always available every day, and there were concerns about staffing during an emergency.
The provider was told to send an action plan. CQC said it would monitor progress and could take further action if needed. The report records breaches of Regulation 12 on safe care and treatment and Regulation 17 on good governance.
Kind and respectful care
Inspectors saw patient and compassionate interactions. Relatives spoke positively about how staff treated their family members.
“People were treated with kindness and compassion and staff demonstrated they respected people's preferences, personal histories and individual identities.” from the report
Health and nutrition
People's nutritional, hydration and healthcare needs were met. The home sought professional help when needed and provided food textures that had been assessed as safe.
“People's nutritional and hydration needs had been assessed and met.” from the report
Clean and well-managed infection control
Inspectors found the home consistently clean and found that COVID-19 risks and infection control arrangements were well managed.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Person-centred information
Care plans included people's preferences, dignity, independence and communication needs. This helped staff provide individualised support.
“Care plans contained person-centred information to assist staff deliver individualised care and support.” from the report
Medicines safety
seriousMedicines were sometimes prepared where staff could be distracted. There were unsecured medicines, recording gaps, dosage information that was not updated promptly and concerns about medicines given covertly.
“We could not be assured that medicines management was consistently safe and followed good practice.” from the report
Emergency staffing
seriousInspectors were not fully assured that there were enough staff on every shift to help people safely in an emergency such as a fire.
“We were not fully assured that there were enough staff to consistently keep people safe in the event of an emergency.” from the report
Mental Capacity Act records
needs fixingThe home was working in people's best interests in practice, but records did not show the required capacity assessments and reviews consistently. CQC made a recommendation about following current guidance.
“Whilst we identified that the service was working in people's best interests in practice, records did not demonstrate this as required by the MCA.” from the report
Family involvement in care reviews
needs fixingRelatives said care plan reviews had not taken place, including where they had wanted or requested them.
“All the relatives we spoke with confirmed no care plan reviews had taken place with some telling us this was wanted or had been requested but not completed.” from the report
Activities
needs fixingRelatives gave mixed views about activities. Records did not show that activities were available every day, although the provider had an action plan to improve this.
“We observed one to one activity being completed at our inspection site visit although records we viewed did not show activities were available every day.” from the report
Quality monitoring
seriousThe home's audits had not found the medicines problems or all the record-keeping and legal compliance issues. The improvement plan was also too limited.
“The provider's quality assurance system had failed to maintain a consistently safe and high-quality service.” from the report
- 01What has changed to make sure medicines are stored securely, prepared without distraction and recorded correctly on every shift?
- 02How many staff are on each shift, and how would you safely support every resident during a fire or other emergency?
- 03How do you assess and review a person's mental capacity before giving medicines covertly or making other decisions on their behalf?
- 04How will relatives be involved in care plan reviews, and when will the next review take place?
- 05What activities are now available each day, and how do you record whether people take part?
This was the home's first comprehensive inspection, covering all five key questions and infection control; there were no previous ratings to carry over. This explanation was written from the published report of 16 September 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 Bay Tree House
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2020
Registered with the Care Quality Commission on 6 November 2020.
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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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.