North Bay House

The provider was previously in breach of the legal regulations in relation to safe care and treatment, staffing, consent procedures, safeguarding, failure to notify reportable incidents, governance and person-centred care. Improvements were found at this inspection, and the provider only remained in breach of 2 legal regulations relating to person-centred care and governance of the service.

The provider had begun to implement changes, including the introduction of new leadership and the development of plans aimed at driving improvement. They demonstrated some improvements in maintaining a safer culture, supported by care planning, and partnership working.

There were systems in place to assess risks to people and ways to reduce them, but these did not always include all risks affecting people to ensure risk mitigation was in place, and guidance for staff was readily available. The quality of risk assessments varied, with some risks being very well detailed whilst others were not. Records were not always accurate and/or complete. This was important as there were new staff working at the service who required accurate guidance to enable them to provide care which was effective and safe.

Oversight of risk relating to people’s skin conditions or injuries such as bruising was improved, but systems in place were not being used effectively to enable the service to monitor healing or indicate how the injuries had been sustained.

Infection prevention and control systems were in place, but these had not always identified issues we found such as rusted equipment which could not be cleaned effectively. We also identified an unsafe piece of toileting equipment which could have caused injury if this had been used by a person. Audits therefore needed to be more robust to capture concerns more effectively.

Records confirmed that people received their medicines as prescribed, however, we noted some gaps in the medication administration records including some related to the day of the site visit. Written guidance for staff about some medicines prescribed for occasional use was not always available. Information that was available for laxative medicines prescribed ‘as required’ lacked information for staff about the maximum period of use for these medicines.

Staff received training relevant to their role, however some additional checks were needed to ensure staff had understood the training they received and implemented this into their day-to-day practice.

Staffing levels were safe, and staff told us they gave people choice and helped them maintain their independence. However, we observed that in practice not all staff delivered care in line with the Mental Capacity Act 2005 (MCA), such as gaining consent prior to assisting people to move. MCA records were more detailed and completed prior to restrictions being implemented to ensure they were the least restrictive option.

Care plans contained more person centred detail, however, there was limited reference to future planning, or consideration of goals or aspirations of each person.

People were supported to take part in activities in the home and community.Activity co-ordinators we spoke with understood the importance of tailored activities to enhance person centred care and had implemented a ‘wish tree’ for people to use.

Staff knew people well and understood their needs and preferences. Most family members told us they were very happy with the service delivery, the provider, and the management team. People had choice over personalising their rooms, and family and friends could visit at any time without prior notice.

There were auditing systems in place, including provider audits. However, audits had not always been sufficiently robust to identify some of the issues we found. During and following the inspection, the registered manager and regional manager took action to begin rectifying areas which required improvement. Action plans were in place and progress was being made.

This service has been in Special Measures since 31 October 2025. The provider demonstrated improvements that have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

We asked the provider for an action plan in response to the concerns found at this assessment.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.