Background to this inspection
Updated
19 April 2019
The inspection:
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
Inspection team:
The inspection was carried out by an inspector, an inspection manager, a specialist professional advisor and an expert by experience. The specialist adviser was a qualified nurse who had expertise of nursing care. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. Our expert by experience had experience of the care of older people living with dementia. We carried out this inspection on 11 March 2019.
Service and service type:
The service is a ‘Care home’. People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided and both were looked at during this inspection.
The service requires a manager to be registered with the Care Quality Commission. The current manager is in the process of applying to be the registered manager. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.’
Notice of inspection: The inspection was unannounced.
What we did:
Before the inspection we reviewed all the information we held about the service. This included notifications the service had sent us. A notification is how providers tell us important information that affects the running of the service and the care people receive. We used the information sent us in the Provider Information Return. This is information we require providers to send us at least once annually which gives key information about the service, what the service does well and improvements they plan to make.
We spoke with 12 people who used the service and five relatives. We spoke with the general manager, peripatetic manager, two nurses, three activity coordinators, four housekeeping staff and ten care staff. We observed care practice and interactions between care staff and people who lived at the service.
We reviewed seven people's care files, medicine administration records, policies, risk assessments, health and safety records, consent to care and quality audits. We looked at three staff files, the recruitment process, complaints, training and supervision records.
The manager sent us information we requested after the inspection and this included evidence of actions taken, lessons learnt and the training and development programme.
Updated
19 April 2019
About the service: Baycroft Great Baddow is a ‘Care home’. People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided and both were looked at during this inspection.
The service is registered to provide personal and nursing care to 64 older and younger people, people with physical, sensory and mental health needs and people living with dementia. At the time of the inspection, 29 people were using the service.
People’s experience of using this service:
People received exceptional personalised care that responded to their needs. They spoke highly of the staff who went the extra mile to provide individualised care.
Information was recorded and used in a way that considered how best to deliver person centred care that improved people's outcomes. This process enabled them to take risks and to live their lives with dignity and freedom.
The manager provided proactive leadership, management skills and was a positive role model. There was an inclusive, open and honest culture in the service with a high level of staff satisfaction. Staff were very happy in their work and created a warm, caring atmosphere and ambience in the service.
Staff used innovative and individual ways of making the service inclusive. They involved people living, working, volunteering and providing services from the community to meet people's needs in a holistic and respectful way. People benefitted from a service which went to great lengths to include and encourage people to be socially engaged and stimulated. Arrangements for social activities was exceptional and personalised.
People were treated with utmost respect and their dignity maintained. Staff knew people well, their family history and backgrounds and used this to enable and encourage people to maintain their interests and celebrate their lifetime achievements. People or their representatives consented to their care and support and the service was working within the Mental Capacity Act 2005.
Systems were in place to protect people from potential harm and people told us they felt safe. There were sufficient numbers of staff who had been recruited safely. People received their medicines by trained staff in the way they wanted them and as prescribed. People were protected by the control of infection as staff wore protective clothing as appropriate.
The training provision was excellent. Staff had access to a comprehensive programme of continuous learning and personal development, support and supervision.
Auditing processes were in place to assess and monitor the quality of the service. Lessons had been learnt and improvements made when things had gone wrong. The service was continually striving to provide a high-quality service.
The service was purpose built and well designed. It was exceptionally well furnished with spacious bedrooms, bathrooms, communal areas and gardens that were well used and brought people together.
Rating at last inspection:
This was the service's first inspection and rating. The service was Good in safe, effective, caring and well led and Outstanding in responsive. It has an overall rating of Good.
Why we inspected: This was a planned comprehensive inspection based on the date the service was registered with CQC.
Follow up: We will continue to monitor the service through the information we receive.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk