CQC report explained · a nursing home
What the CQC found at Baylham Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2021
Baylham Care Centre was rated Requires Improvement and is no longer in Special Measures; inspectors found kind care and progress, but pressure care records and leadership still need improvement.
This was an unannounced inspection on 15 September 2021. Inspectors spoke with people living at the home, relatives and staff. They reviewed care files, daily records, medicines records, staff files, complaints and quality checks.
The home was rated Good for Effective, Caring and Responsive care. People were treated kindly, their care preferences were recorded, medicines were managed safely and staff worked with health professionals when needed.
Safe and Well-led were rated Requires Improvement. Records did not always show that people at risk of pressure ulcers were repositioned as planned. There had been no registered manager since January 2021, and some care records and daily tasks were not recorded consistently.
The previous inspection rated the home Inadequate and found multiple breaches. Inspectors found enough improvement for the home to be no longer in breach of regulations or Special Measures, but said improvements needed to be sustained and embedded.
Kind and respectful care
People and relatives gave positive feedback about staff's kindness, respect and patience. Inspectors observed friendly and engaging interactions.
“People were well treated and supported by kind and caring staff.” from the report
Medicines managed safely
Medicines were stored securely. Temperature checks, audits and stock checks were completed, and the stock balances checked during the inspection were accurate.
“Systems in place helped to ensure medicines were managed safely.” from the report
Improved learning from incidents
Incident records contained more detail and were analysed for patterns and trends. Inspectors found fewer accidents and incidents than at the previous inspection.
“Records contained a greater level of detail, incidents were logged and analysed to look for any themes and trends” from the report
Better support and training
Staff had the skills and training needed for their roles. Supervision had become more frequent and specialist mental health training had taken place.
“Staff had the training, skills and experience to carry out their roles effectively” from the report
Pressure care records
seriousA care plan said one person should be repositioned every two hours, while the chart said four hours. Repositioning records had gaps, so staff could not be confident that pressure care was being carried out as planned.
“Records of assisting people to reposition contained gaps which meant staff could not be confident that the person had been assisted to change their position” from the report
No registered manager
needs fixingThe home had been without a registered manager since January 2021. Inspectors said consistent management was needed to make sure improvements became part of everyday practice.
“The service has been without a registered manager since 4 January 2021.” from the report
Staffing levels
needs fixingPeople, relatives and some staff reported that staffing was sometimes insufficient and call bells could take longer to answer. Inspectors observed enough staff during their visits and recommended closer monitoring.
“We recommend that the provider continues closely monitoring and reviewing staffing levels using an effective tool” from the report
Inconsistent daily recording
needs fixingNot all daily tasks were recorded. Inspectors said this created a risk that planned care might not be delivered or that unsafe care might not be identified.
“There were inconsistencies in the care planning of people's repositioning checks and not all daily tasks were recorded by staff.” from the report
- 01How do you now make sure people with pressure ulcers are repositioned at the frequency set out in their care plan?
- 02Who is currently managing the home, and what is the progress towards appointing and registering a manager?
- 03How do you check that all planned daily care tasks are completed and recorded?
- 04How do you monitor staffing levels during busy periods, and what happens if there are not enough staff?
- 05What activities are currently available, and how do you make sure people can continue their hobbies and interests?
This was a planned, unannounced inspection covering all five key questions and infection prevention and control, following the previous Inadequate rating. This explanation was written from the published report of 16 November 2021 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, March 2021
Baylham Care Centre was rated Inadequate and placed in special measures; inspectors found serious risks to people's safety and weak management.
Inspectors visited on 12 February, 23 February and 9 March 2021. They spoke with people, relatives, staff and healthcare professionals. They reviewed care records, medicines, training, complaints and quality checks.
The main concerns were poor risk management, incomplete care records, safeguarding failures and gaps in staff training. Staff did not always have enough guidance or skills to support people with complex needs and behaviours that may challenge. Mental Capacity Act and best-interests processes were not always followed.
Inspectors found some positive care. People were often happy, staff were described as caring, medicines were managed safely and infection control arrangements were mostly suitable. However, these strengths did not outweigh the significant safety and leadership failures.
The overall rating was Inadequate. Safe and well-led were rated Inadequate, while effective, caring and responsive were rated Requires Improvement. This was the first ratings inspection since the service was newly registered under the provider.
Medicines
Inspectors found that medicines were administered, stored and recorded safely. Regular audits were in place.
“Medicines administration records indicated people received their medicines as prescribed.” from the report
Infection control
The home had arrangements for preventing and managing infections during the COVID-19 pandemic. Inspectors were assured about testing, PPE, admissions and outbreak procedures.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Caring staff
Many people and relatives said staff were kind and that people were happy living in the home.
“Most people, and their relatives, that we spoke with told us they were happy and enjoyed living at the service.” from the report
Support at mealtimes
Staff supported people calmly at mealtimes. People at nutritional risk had their weight and food and fluid intake monitored.
“We observed staff supported people in a calm unhurried manner with their meal.” from the report
Serious safety risks
seriousRisks were not consistently assessed or reduced. Inspectors found unsecured doors, unfixed wardrobes, unsafe balcony furniture and inadequate plans for people at risk of self-harm or suicide.
“Risks to people's health, safety and welfare were not managed effectively, placing them at significant risk.” from the report
Safeguarding failures
seriousPotential abuse and unexplained injuries were not always reported to the local authority. Incident records did not always show that concerns had been followed up properly.
“The provider had not recognised potential safeguarding concerns or reported concerns such as unexplained injuries, to the local authority in line with local safeguarding protocols.” from the report
Staff skills and communication
seriousTraining and supervision were not up to date in several areas. Some agency staff had limited English language skills, and staff supporting complex needs did not always have the necessary training or experience.
“There were gaps in the skills and knowledge of staff across multiple areas of the service such as, safeguarding people from the risk of abuse, fire safety, moving and assistance and positive behaviour support.” from the report
Care records and consent
seriousCare plans and risk assessments did not always explain how to support people safely and consistently. Capacity assessments and best-interests decisions were not always completed correctly.
“Not all care plans contained sufficient information to ensure staff knew how to deliver people's care in a safe and person-centred way.” from the report
Weak management oversight
seriousAudits had not identified important problems, and known issues were not dealt with quickly. There was no registered manager at the time of the inspection and there had been several management changes.
“The provider's quality assurance systems were not robust.” from the report
Complaints and activities
needs fixingRelatives gave mixed feedback about how to make complaints, and learning from complaints was not consistently recorded. Some people with complex needs had limited opportunities for activities, although the pandemic affected this.
“Learning was not consistently taken forward and recorded meaning the service did not always learn from concerns raised and use them as a means identify improvements.” from the report
- 01What immediate action has been taken to manage risks involving doors, balconies, unfixed furniture and people at risk of self-harm?
- 02How do you make sure agency staff understand each person's care plan and can communicate safely with people and other professionals?
- 03Which staff training and supervision gaps identified by CQC have now been completed?
- 04How are capacity assessments, best-interests decisions and Deprivation of Liberty Safeguards now checked?
- 05How will you show that safeguarding concerns, complaints and audit findings are reported, investigated and acted on?
This was a full first ratings inspection covering all five key questions and infection prevention and control; the previous Outstanding rating was under a different provider. This explanation was written from the published report of 31 March 2021 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 Baylham Care Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- November 2021Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2020Inspected but not ratedSafe: Inspected but not rated
- October 2017Outstandingup from GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- September 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2019
Registered with the Care Quality Commission on 9 September 2019.
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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23 live-in carers within about an hour of Suffolk
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 £1,020 to £1,260 a week. 17 can care for a couple. 7 years' experience on average.
“Not only was she professional, polite and efficient but she bought a lovely smile and laughter to my parents home.”
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.