CQC report explained · a residential care home
What the CQC found at Baytree 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
- People were safer than at the previous inspection, with better safeguarding, medicine management, infection control and incident learning. However, some individual and environmental risks, including sensory needs and positive risk-taking, were not fully recorded.
- Effective?
- Requires improvement
- People were more involved in everyday tasks and activities, and staff training had improved. Care plans still lacked enough detail about people's goals, communication, sensory needs and how staff should support them consistently.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Leadership, training oversight and incident learning had improved. However, the quality assurance system was new and staff competency checks, risk assessments and governance arrangements were still being developed.
What inspectors found, April 2022
Requires Improvement; improvements ended Special Measures, but inspectors found unfinished work on risk records, care plans and quality checks.
Inspectors made an unannounced, focused visit over 14 and 15 March 2022. They spoke with seven people, two relatives, seven staff and one visiting professional. They reviewed care records, medicine records, staff files and management records.
The home had improved since its previous Inadequate rating. People were safer, medicines were managed better, staff had more training and people were more involved in cooking, cleaning, activities and daily decisions. Inspectors saw kind and respectful care.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also Requires Improvement. This means some care and management were still inconsistent, records did not always give staff enough guidance, and there was limited assurance about safety. Caring and Responsive were not inspected in this visit, so their previous ratings were carried forward.
More independence
People were increasingly involved in ordinary daily tasks and activities. Inspectors saw people preparing food, cleaning, doing laundry and making choices.
“People were supported to be involved in ordinary daily activities such as housework.” from the report
Kind and respectful care
Inspectors observed compassionate care. Staff respected people's privacy, dignity, choices and communication methods.
“We observed people receiving kind and compassionate care.” from the report
Improved medicines safety
Medicine arrangements had improved, including clearer guidance for as-required medicines, better storage and checks of staff practice.
“Medicine management systems had improved and this inspection found errors were now identified when they occurred.” from the report
Better safeguarding
Staff understood how to recognise and report abuse and restrictive practice. The home had stopped telling people to go to their rooms when distressed.
“Staff were now clear about their role. They were identifying, reporting and taking appropriate actions.” from the report
Learning from incidents
Managers investigated incidents, looked for patterns and shared learning. Reflective practice tools were being used to consider what could be done differently.
“The service managed incidents affecting people's safety well.” from the report
Risk information was incomplete
needs fixingSome sensory needs and positive risk-taking plans were not recorded. Staff knowledge was therefore relied on, which could make support less consistent for new or agency staff.
“These details were not recorded and relied on staff knowing people well.” from the report
Communication and sensory work was unfinished
needs fixingCommunication plans had improved, but further learning and assessments were needed. The building had not yet been adapted to meet people's sensory needs.
“The interior decoration of the service was not adapted in line with good practice to meet people's sensory needs.” from the report
Quality checks were new
needs fixingA formal quality assurance system had only recently started. Inspectors said it needed more time to show that it was effective, and staff competency checks were still developing.
“The new quality assurance system had only had one full month in use at the time of the inspection and needed time to develop and demonstrate its effectiveness.” from the report
- 01How have you completed and updated each person's sensory assessment and risk guidance?
- 02How do care plans now record each person's goals, abilities and the exact support staff should provide?
- 03How are you checking that new and agency staff understand people's communication and sensory needs?
- 04What evidence now shows that the new quality assurance system is identifying and fixing problems?
- 05How are you completing staff competency checks, particularly for positive behaviour support and communication?
This was an unannounced planned focused inspection of Safe, Effective and Well-led, including infection prevention and control; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 26 April 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.
What inspectors found, January 2022
Rated Inadequate and in special measures; inspectors found unsafe care, weak oversight and staff training shortfalls despite positive views from people and relatives.
This was an unannounced inspection on 30 September 2021. Inspectors spoke with six people, two relatives, five staff members and two visiting professionals. They reviewed care records, medicines records, staff files and management records.
Inspectors found serious safety problems. Safeguarding concerns were not always reported, risks such as choking and fire evacuation had not been properly assessed, and medicines were not always managed safely. Infection control practices also needed improvement.
Staff knew people well and people and relatives spoke positively about the home. However, staff did not consistently have the training, induction or guidance needed to support people with learning disabilities and autistic people. Care did not always promote people's independence, communication, strengths or aspirations.
The overall rating was Inadequate. Safe and well-led were rated Inadequate, and effective was rated Requires Improvement. Caring and responsive were not separately rated in this report. The previous overall rating was Good, published on 27 September 2019.
Kind and available staff
People said staff were kind and had time to talk. Inspectors saw staff respond promptly when people needed help.
“There were sufficient staff to meet people's needs. We observed staff were prompt in supporting people who needed assistance.” from the report
Positive relationships
People appeared relaxed with staff and spoke positively about the home. Relatives also expressed confidence in the home manager.
“People were positive about their experience of the service.” from the report
Healthcare support
People were supported to access healthcare. Hospital care passports were up to date, and a visiting health professional said advice was followed.
“Often I have given (health) advice to staff/management and this has always been followed through.” from the report
Food and activities
People enjoyed the meals and had choices that considered dietary needs. Activities included walks, shopping and arts and crafts.
“People told us they enjoyed the meals and had plenty to eat.” from the report
Safeguarding failures
seriousFour incidents involving one person slapping another were not all reported to the local authority safeguarding team. The report also found concerns about restrictive practices.
“People were not safe from abuse. Systems and processes to protect people from the risk of abuse were not operating effectively.” from the report
Risks not assessed
seriousImportant risks, including choking, fire evacuation, hot radiators and use of a stair lift, were not always assessed or recorded. This left staff without clear guidance.
“The failure to assess, record and mitigate risks to people's health and safety was a breach of regulation.” from the report
Unsafe medicines processes
seriousSome as-required medicines did not have clear instructions. Medicines were given away from the records needed to check them, and audits did not identify these problems.
“People did not always receive their medicines safely or in accordance with the prescriber's instructions.” from the report
Insufficient training
needs fixingMost staff had not received recent training about learning disabilities and autism. Staff had not been offered the Care Certificate, and not all staff had training in Makaton or restrictive practices.
“The provider failed to ensure staff received appropriate training and support to enable them to meet people's needs.” from the report
Care was not person-centred enough
needs fixingCare plans did not always include communication or sensory needs, proactive ways to reduce distress, or plans to develop people's strengths and interests.
“People did not have individualised care in line with their preferences and assessed needs.” from the report
Weak management oversight
seriousAudits and governance systems did not identify repeated safety problems or ensure improvements were made. The provider also failed to notify CQC about some incidents.
“The provider had failed to establish adequate systems and processes to assess and improve the quality and safety of the service provided or to assess and monitor risks.” from the report
- 01What has changed since the inspection to make sure all safeguarding incidents are recognised and reported promptly?
- 02What current risk assessments and staff instructions are in place for choking, fire evacuation, hot radiators and the stair lift?
- 03How are medicines, especially as-required medicines, now checked and audited?
- 04Which staff have completed training in learning disability, autism, Makaton and positive behaviour support?
- 05What evidence can you show that care plans now cover communication, sensory needs, distress triggers and people's personal goals?
This inspection reported ratings for Safe, Effective and Well-led; Caring and Responsive were not separately rated in the report. This explanation was written from the published report of 14 January 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 Baytree House
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- April 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022Inadequatedown from GoodSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- September 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- January 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
28 live-in carers within about an hour of West Sussex
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 £1,170 a week. 23 can care for a couple. 11 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.