10 August 2021
During an inspection looking at part of the service
People’s experience of using this service and what we found
We found a breach of our regulations at this inspection because the providers system for monitoring the quality and safety of the service had not ensured that medicine administration records (MARs) were completed accurately. This is despite our findings at out last inspection in August 2019 where we reported that improvement was required to ensure medicine administration records (MARs) were always completed accurately.
People told us they felt safe. There were safeguarding policies and procedures in place and staff had a clear understanding of these procedures. Appropriate recruitment checks took place before staff started work and there were enough staff available to meet people’s care and support needs. Risks to people were assessed and staff were aware of the action to take to minimise risks where they had been identified. The service had procedures in place to reduce the risk of infections and COVID 19.
The provider took people’s views into account through satisfaction surveys and feedback from these was used to improve the service. People and their relatives were positive about the service they received. Staff said they received good support from the registered manager. The registered manager and staff worked with health and social care providers to deliver an effective service.
Rating at last inspection
The last rating for this service was requires improvement (published 25 September 2019) as we found a breach of our regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.
Why we inspected
We received concerns in relation to people’s nursing care needs and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has remained the same. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvements. You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for
Baycroft Grays Farm Road on our website at www.cqc.org.uk.
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.