Archived: Baycroft Grays Farm Road

Updated 11 September 2021

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. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors and a specialist nurse advisor carried out this inspection. They were supported on site by Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. A CQC pharmacy inspector provided medicines advice remotely.

Service and service type

Baycroft Grays Farm Road is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection and sought feedback from the local authority and local clinical commissioning group (CCG). We also reviewed the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used this information to plan our inspection.

During the inspection

We spoke with seven people who used the service and two relatives about their experience of the care provided. We spoke with ten members of staff including the area manager, the providers clinical governance lead, registered manager, a nurse, a care worker, an activities worker, two housekeeping staff and the chef. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.

Updated 11 September 2021

Baycroft Grays Farm Road is a care home providing personal and nursing care for up to 75 people. There were 18 people receiving support at the time of our inspection. The home accommodates people across three floors. Only two of the floors were being used at the time of the inspection. One of the floors specialises in providing care for people living with dementia.

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.