CQC takes action to protect people at North Bay House in Suffolk

The Care Quality Commission (CQC) has dropped the rating of North Bay House from good to inadequate and taken enforcement action to protect people, following an inspection in August.

North Bay House is a care home for up to 29 older people and is run by Hellendoorn Healthcare Limited. There were 27 people living at the home during this visit.

CQC carried out this inspection in part due to concerns received about the quality of care people were receiving, as well as the staffing and management of the home.

Inspectors found these concerns were substantiated and found serious issues around people's safety and the management of the service. Because of this, CQC has imposed urgent conditions on the home's registration. These require leaders to make immediate improvements to people's safety, and update CQC weekly on any incidents that occur and how risks are being reduced. These conditions also prevent North Bay House from admitting new residents or re-admitting previous residents without CQC's permission.

CQC has also placed the service in special measures, meaning inspectors will closely monitor the home to keep people safe while improvements are made.

CQC has dropped the home's ratings for safe, effective, caring, and well-led from good to inadequate. CQC has downgraded its rating for responsive from good to requires improvement.

Hazel Roberts, CQC deputy director of operations in the East of England, said:

"When we inspected North Bay House, we were concerned to find low staffing had undermined people's care. When this caused people harm or put them in danger, leaders didn't always investigate or make changes to protect people in the future.

"Our inspection team saw one person hit another resident in the dining room when no staff were present. When looking into this incident, we found this had happened before, but plans weren't put in place to ensure that this didn't happen again and to protect people from coming to harm.

"Leaders had also failed to investigate or act after other incidents took place, such as when a person fell down the stairs or when another person choked. As leaders hadn't investigated these incidents promptly, they'd missed opportunities to learn and protect people from repeated mistakes.  

"Additionally, as there weren't enough staff around, multiple people asked inspectors for support, and some people sat for long periods of time without being offered any activities, which was affecting their wellbeing.

"Staff didn't have time to get to know people well and didn't always involve them in decisions about their care. This meant the home didn't always support people as individuals or tailor care to their unique needs.

"We've shared our findings with the home's management and imposed conditions on its registration to focus their attention on making rapid improvements. We'll continue to monitor the home closely while this happens to ensure people are kept safe."

Inspectors found:

• Staff were focused on tasks instead of the people in their care. Some felt well looked after, but others felt staff could be rude or curt.
• Staff didn't always respect people's consent during care and didn't always know how to protect the rights of people with limited mental capacity.
• The home didn't always support people to reduce their future care needs, such as by remaining physically active and cognitively stimulated.
• Leaders didn't ensure the environment was always safe, particularly for people living with dementia. Bleach tablets had been left out, some people had fall risks in their bedrooms, and some parts of the home were unclean.
• The home didn't always manage people's medications safely.
• Some staff didn't feel safe speaking up with concerns. This could further undermine people's safety, as staff have important information to share.
• Care plans didn't guide staff on how to support people experiencing distress, and some had experienced abuse from distressed residents. Leaders hadn't de-briefed staff afterwards to ensure they were supported and felt safe.