Baylham Care Home

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.The service was mostly meeting the principles of Right support, right care, right culture, however, some of the practices at the service restricted people’s choices.

Since our last inspection, where the service was rated inadequate and in breach of multiple regulations, Baylham Care Home had undergone significant leadership and management changes. This inspection found early signs of improvement; however, progress was inconsistent, and a number of shortfalls remained, particularly in relation to medicines management, governance, care planning and risk management. The service remained in breach of the regulations in the safe management of medicines and good governance.

People were not consistently protected from avoidable harm. While systems for incident reporting, safeguarding and learning from events had improved since the last inspection, care plans and risk assessments were not always detailed or person‑centred, and some contained contradictory information. This meant staff did not always have clear guidance to support people safely while promoting their independence. Environmental risks also remained, with areas of the service still requiring refurbishment.

There were significant concerns about the safe management of medicines. Systems to ensure medicines were stored, administered and monitored safely were not robust including the administration of expired medicines, inappropriate storage of fluid thickener, incomplete medicines records, gaps in end‑of‑life medicines planning and unsafe administration equipment. Although some immediate actions were taken during the inspection, these concerns placed people at ongoing risk of harm and demonstrated a lack of effective oversight.

Staffing deployment was inconsistent. Feedback from people, relatives and staff about staffing remained mixed, with concerns about delays to care, particularly at weekends. Although training opportunities had improved and safer recruitment processes were in place, staff were not always effectively deployed to meet people’s needs. Staff well-being and morale were also impacted by recent and ongoing changes, with some staff reporting they did not feel safe or confident to raise concerns, however, other staff positive about the direction the service was taking and the improvements the new manager was making.

The newly appointed manager, who had been in post for a short period, demonstrated an understanding of the significant challenges that were within the service and had begun to implement action plans and monitoring systems. There were early signs of improved leadership visibility and accountability; however, governance systems had not yet been fully embedded or effective in identifying risks, driving improvement and ensuring issues identified at previous inspections were fully addressed.