The Care Quality Commission (CQC) has told Bay House in Buckinghamshire to make immediate improvements and kept it in special measures to protect the safety and welfare of people living there. The service has again been rated as inadequate following an inspection that took place from May to June.
Bay House, run by Olney Care Homes Limited, is a residential care home that provides support to older people and people living with dementia.
This inspection was prompted to check on the progress of improvements they were told to make following their previous inspection when they were first rated as inadequate.
Following this inspection, Bay House has again been rated inadequate overall. They have again been rated as inadequate for how safe and well-led they are. The ratings for responsive, effective and caring were not inspected and remain rated as good.
CQC have also taken further regulatory action to protect people, which Bay House have the right to appeal to and will report on this when legally able to do so.
Inspectors found:
- Window restrictors were missing for some windows on the first floor, and where restrictors were installed, they didn't meet Health and Safety Executive (HSE) requirements. This poses a risk of falls from height for the residents
- Fire doors didn't always function correctly, with missing smoke seals and doors that failed to close properly. The environment was unsafe, placing residents at significant risk of harm
- Medicines weren’t always managed safely. Inspectors found instances where residents were at risk of receiving incorrect medication due to poor record-keeping and unclear instructions for administering topical medicines. This also increased the risk of infection, as creams may have been shared between residents
- Multiple areas of the home were visibly dirty and could not be properly cleaned, increasing the risk of infection. There was damaged and rotten flooring in a bedroom, as well as evidence of mould
- Leaders at Bay House didn't promote a learning culture. Staff didn't report incidents effectively and incidents weren't actively investigated, leading to missed opportunities for improvement.
The full report with detailed findings will be published on CQC’s website in the next few days.
Falls from windows often result in serious or fatal injuries but are preventable. Providers must assess risks and, where the risk of someone falling from a high window is identified, must take adequate precautions, such as fitting window restrictors. CQC has prosecuted six organisations since 2018 for not ensuring people’s safety in relation to windows. All providers are encouraged to remind themselves about window safety via CQC's website.