CQC report explained · a residential care home
What the CQC found at Baytrees
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found enough staff, safe recruitment, suitable risk assessments and generally safe medicines arrangements, but one as-required medicine lacked a written protocol.
- Effective?
- Good
- People had detailed assessments and support plans. Staff had relevant training and supervision, and people were supported with food, communication, healthcare and decisions about their care.
- Caring?
- Good
- Staff treated people with kindness, patience, dignity and respect. People were supported to communicate in their own ways, make choices and build independence.
- Responsive?
- Good
- People were supported to follow their interests, maintain relationships and take part in community activities. However, some care records used outdated or unsuitable language and did not fully reflect the care provided.
- Well-led?
- Good
- Managers were visible and approachable, and staff and relatives spoke positively about the leadership. Quality checks, staff supervision and feedback systems were in place.
What inspectors found, June 2022
Baytrees was rated Good; inspectors found kind, safe and person-centred care, but some care records did not reflect best practice.
This was an unannounced inspection on 16 and 17 May 2022. Inspectors spoke with all 10 people living at the home, two relatives and seven staff. They reviewed care, medicines, staffing, training, complaints and management records, and sought views from health professionals.
The overall rating was Good. Each of the five areas was also rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were safe, treated with kindness and supported to make choices, develop independence, follow their interests and access healthcare.
There were some areas to improve. The provider was not always using current best-practice formats or language in care records. Most people did not have communication passports, although their communication needs were assessed and staff understood how to communicate with them. One as-required medicine did not have a written protocol, and the manager said this would be corrected.
Choice and independence
People were supported to make decisions, go out, follow their interests and develop everyday skills. Staff used the least restrictive approach and involved people in their care.
“People were supported to have the maximum possible choice, independence and control over their own lives.” from the report
Kind communication
Staff understood different ways people communicated, including Makaton, pictures, sounds and body language. Inspectors saw patient and respectful interactions.
“People who had individual ways of communicating, using body language, sounds, Makaton (a form of sign language), pictures and symbols could interact comfortably with staff” from the report
Activities and community life
People were supported to pursue hobbies, go on holidays, use local services and take part in community events. Staffing levels allowed people to go out when they wished.
“People went out often and accessed local health services; they regularly went on holiday and were supported to follow their dreams and aspirations.” from the report
Consistent staff team
Inspectors found enough staff and no vacancies. A stable team knew people's individual needs and helped provide consistent support.
“The service had a consistent staff team and no staffing vacancies which promoted continuity and ensured safe and consistent care.” from the report
Positive leadership
Managers worked directly with people, welcomed feedback and used audits, meetings and supervision to monitor and improve the service.
“Quality assurance and management systems provided managers with sufficient oversight and enabled effective governance of the service.” from the report
Care records used unsuitable language
needs fixingSome care plans used terms such as 'challenging behaviour' and 'lack of appropriate behaviour'. The provider and manager were not always using recognised best-practice formats for recording people's needs and choices.
“The provider and manager were not always familiar with; and were not using evidence best practice formats for documenting and recording people's needs and choices.” from the report
Records did not always match practice
needs fixingInspectors found that the written records did not fully describe the care people actually received. The management team said they would improve their knowledge and the records.
“What was recorded and what support looked like in practice was very different.” from the report
Communication passports missing
needs fixingMost people could not speak verbally and did not have communication passports. Inspectors still found that staff understood people's communication needs and used suitable methods.
“The majority of people were unable to speak with us verbally and did not have a communication passport.” from the report
Written medicine instructions
needs fixingOne person had an as-required medicine for constipation without a written protocol explaining when, how and what dose to give. Staff knew the instructions, and the manager said the records would be updated.
“The one person prescribed PRN medicine for symptoms of constipation did not have a protocol in place for staff to guide them when, how and what dose of the medicine was required.” from the report
- 01Have all care plans been rewritten using current best-practice language and formats?
- 02How do you make sure each person's written records accurately describe the care they receive?
- 03Does every person who needs one now have a communication passport, and how is it kept up to date?
- 04Has the written protocol for the as-required constipation medicine been completed and checked?
- 05Who is currently the registered manager, and what is the progress of the new manager's registration?
This was an unannounced inspection covering all five quality areas, the care and premises, and infection prevention and control; all five ratings remained Good from the previous inspection. This explanation was written from the published report of 22 June 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, April 2021
Baytrees was inspected but not rated; inspectors were assured that infection control arrangements were safe.
This was an unannounced, targeted inspection on 8 March 2021. It looked only at infection prevention and control, including visiting, testing, protective equipment, cleaning and arrangements for outbreaks.
Inspectors found that people, staff and visitors had access to protective equipment. Staff were trained in coronavirus procedures and lateral flow testing. Visitors were tested on arrival and needed a negative result before entering.
The home had adjusted its layout for distancing and had arrangements for isolation and shielding. It was clean and free from unpleasant smells. Inspectors were assured that infection prevention and control processes were being followed.
The service was not given an overall or question rating. This report does not provide a full assessment of the quality of care in other areas.
Safe visiting
The provider worked with people, friends and family to start safe visiting under the new guidance in force on the inspection day.
“The provider had worked with people and their friends and family to enable safe visiting to commence from this date.” from the report
Testing and protective equipment
People and staff took part in regular COVID-19 testing. Staff were trained to carry out lateral flow tests, and visitors were tested before entry.
“Visitors required a negative test result before being granted entry to the service.” from the report
Clean environment
The home was clean and free from unpleasant smells. Cleaning schedules included regular cleaning of frequently touched areas.
“The service was clean and odour free. Cleaning schedules ensured regular cleaning took place including enhanced cleaning of high touch areas.” from the report
Support during restrictions
The home had arrangements for isolation and shielding and supported people to stay in touch with family and friends through several forms of contact.
“People had remained in contact with family and friends through video calling, telephone and written correspondence.” from the report
Inspectors raised no specific concerns in this report.
- 01What are your current arrangements for family visits and visitor testing?
- 02How do you currently provide and monitor personal protective equipment for staff and visitors?
- 03How do you support people to stay in contact with family and friends if visits are restricted?
- 04What arrangements are in place now for isolation, shielding and managing infection outbreaks?
- 05What are the home's current ratings for caring, effective care, responsiveness and leadership, since this inspection did not assess them?
This was an unannounced targeted inspection of infection prevention and control only; the service was inspected but not rated and the other care areas were not assessed. This explanation was written from the published report of 9 April 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 Baytrees
3 rated inspections over 7 years: the service has held its Good rating throughout.
- June 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2021Inspected but not ratedSafe: Inspected but not rated
- December 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
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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Most charge £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
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