CQC report explained · a nursing home
What the CQC found at Baytrees Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some medicines were not disposed of safely and some were not clearly labelled. Inspectors also found that staff were not initially wearing disposable masks as required.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- The systems for checking the service had not identified the medicines problems. Some other audits were effective, and people and staff were involved in the service.
What inspectors found, June 2022
Baytrees Nursing Home rated Requires Improvement; inspectors found unsafe medicines storage and weak oversight, although people described kind, personalised care.
This was an unannounced inspection on 17 May 2022. One inspector spoke with four people, staff, management and a visiting healthcare professional. The inspector reviewed care plans, medicine records, recruitment files and management records.
The main safety problem was medicines. Some medicines had not been disposed of properly, some labels had been removed and some medicines had been taken out of their packaging. This created a risk that people could receive medicines prescribed for someone else. Staff removed the medicines during the inspection.
The home was clean and well-maintained. People said they felt safe, staff were available and care was personalised. However, audits had not found the medicines problems, so the overall rating and the ratings for Safe and Well-led fell from Good to Requires Improvement.
Kind and personalised care
People described good care and said they could make choices. Staff understood people's preferences and supported their individual needs.
“The care is good and I can't fault it. I can go out if the weather's nice, to the shops, the beach or on the pier. We can choose” from the report
Enough trained staff
Inspectors found enough trained staff to meet people's needs. Recruitment checks, including references and DBS checks, had been completed for the staff files reviewed.
“There were sufficient trained staff to meet people's needs.” from the report
People felt safe
People told inspectors they felt safe. Staff had safeguarding training and knew how to report concerns.
“People told us they felt safe living at the home. One person said, "I do feel very safe. Staff keep outside doors locked so I do feel secure".” from the report
Risks were assessed
Care plans included risk assessments for areas such as falls, nutrition, hydration and skin care. Fire safety checks and emergency evacuation plans were also in place.
“We reviewed a range of risk assessments, including for skin integrity, nutrition and hydration, continence and catheter care.” from the report
Medicines were not always safe
seriousSome medicines had not been disposed of after they were no longer needed. Others had no clear label or had been removed from their packaging, creating a risk of the wrong person receiving them.
“People were at risk of receiving medicines that had not been prescribed for them.” from the report
Checks missed important problems
needs fixingThe home's monitoring systems and audits did not identify the medicines problems found by inspectors. The provider was asked to improve its systems.
“Issues found at this inspection and written about in the Safe section of this report had not been identified through the audits.” from the report
Masks were not worn at first
needs fixingWhen the inspector arrived, staff were not wearing disposable face masks. They started wearing them after the manager arrived and the guidance was discussed.
“When we arrived at the home, we observed that no staff were wearing disposable face masks.” from the report
- 01What changes have you made to make sure unwanted medicines are disposed of promptly and safely?
- 02How do you check that every medicine is clearly labelled and linked to the correct person?
- 03What new audits or checks now test medicines storage and disposal, and who reviews the results?
- 04How do you make sure staff follow the current rules on wearing disposable masks?
- 05What progress has been made on the action plan requested after this inspection?
This was an unannounced inspection focused on Safe and Well-led; the other key question ratings were not inspected and carried forward from the previous inspection. This explanation was written from the published report of 29 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, July 2021
Baytrees Nursing Home was rated Good; inspectors found safe, personalised care and stronger management systems.
Inspectors visited on 18 June 2021. They spoke with people living in the home, relatives, staff and a visiting professional. They reviewed care records, medicines records, staff files and management documents.
The home was rated Good overall. Safe and well-led were both rated Good. Inspectors found enough trained staff, safe medicines practices, suitable risk assessments and effective infection control arrangements.
People received individualised support and were offered choices about their care, food, drinks and activities. Staff worked with health professionals when people needed specialist help.
This was a focused inspection. Some areas were not inspected because no concerns had been identified, so earlier ratings for those areas were carried forward. The well-led rating improved from Requires Improvement at the previous inspection to Good.
Personalised support
People had different mental health, physical health and personal needs. Inspectors found that staff adapted support to individuals and respected their choices.
“People had a wide range of needs and diverse backgrounds, they received individualised support from staff.” from the report
Enough trained staff
Staffing levels were based on people's needs. Inspectors observed staff responding promptly to call bells and providing one-to-one support where required.
“There were enough staff to meet people's needs.” from the report
Safe medicines
Trained staff were assessed as competent to administer medicines. The home had systems for storing, ordering, giving and disposing of medicines.
“People were administered their medicines safely by trained staff who were assessed as competent by the management.” from the report
Improved leadership
The home had addressed earlier concerns about quality checks, staff training and care records. Inspectors found that monitoring systems were now embedded.
“Previous concerns relating to assessing and monitoring the quality of services had been addressed by training and increased monitoring by the management team.” from the report
Professional support
The home worked with specialist professionals, including speech and language therapists and tissue viability nurses, to improve people's care and health outcomes.
“A variety of professionals including SaLT, Tissue Viability Nurses (TVN) and the Living Well with Dementia team, had been involved” from the report
Inspectors raised no specific concerns in this report.
- 01How do you now monitor care records and risks using the new electronic care management system?
- 02How are medicines checked, including as-required medicines, and how is staff competence reviewed?
- 03How do you decide staffing levels when people's needs or the home's occupancy changes?
- 04Which health professionals would be involved if my relative needed specialist support?
- 05How are visits managed and what infection control arrangements would apply to my relative and our family?
This was a focused inspection of Safe, Effective and Well-led, with infection control included; other key question ratings were carried forward from earlier inspections because they were not inspected. This explanation was written from the published report of 21 July 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 Nursing Home
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021Goodstayed GoodSafe: GoodWell-led: Good
- May 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- November 2018Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2016Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 13 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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