About the service: Baedling Manor is a care home which is registered to provide personal care and accommodation for up to 50 people, some of whom are living with dementia. There were 45 people living at the home at the time of the inspection.

People’s experience of using this service: We found people were receiving safe care at the time of the inspection. Action had been taken to address the concerns that had been raised.

We found audits and checks continued to be carried out but they had not picked up on all the issues we identified during the inspection. We have made a recommendation about closely monitoring the effectiveness of governance systems, particularly with the increase in numbers of people using the service.

Rating at last inspection: Good (report published 17 July 2018)

Why we inspected: We carried out an unannounced comprehensive inspection of this service on 22 May 2018. More recently, we received concerns in relation to the management of medicines, pressure ulcers, staffing and infection control. As a result, we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to these topics. We looked at the key questions ‘Is this service safe?’ and ‘Is this service well-led?’

We did not inspect the key questions ‘Is this service effective, caring, or responsive’ as our ongoing monitoring did not raise any information about risks or concerns in these areas.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate and high quality care. Further inspections will be planned for future dates.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

The inspection took place on the 22 May 2018 and was unannounced. We carried out two further visits to the home on 23 and 24 May 2018 to complete the inspection.

Baedling Manor is a 'care home' People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home can accommodate up to 50 people. There were 26 people living at the home at the time of the inspection.

This was the first inspection of the home since the service first registered with the Care Quality Commission [CQC] in June 2017.

A registered manager was in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. The local authority safeguarding team told us that there were no organisational safeguarding concerns regarding the home.

The furnishings and fittings were luxurious and all areas of the building were well maintained. People and relatives were very complimentary about the premises. One person told us, “It’s like a five star hotel.”

There were sufficient staff deployed. Safe recruitment procedures were followed and staff had completed training in safe working practices. There were safe systems in place to receive, store, administer and dispose of medicines.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in place supported this practice. The registered manager was strengthening the home’s documentation to ensure that records reflected how the Mental Capacity Act [2005] was followed in practice.

We observed that staff supported people with their dietary requirements. We spoke with the head chef and chef who spoke passionately about ensuring people’s nutritional needs were met and that the meals provided at the home were of the highest standard.

Staff were motivated and committed and spoke with pride about the importance of ensuring people's needs were held in the forefront of everything they did. One staff member told us, “It’s passionate care here.”

Staff were knowledgeable about people’s preferences and life histories. We have made a recommendation that people’s electronic care plans reflect this information.

There was an activities coordinator employed to help meet the social needs of people. A varied activities programme was in place. The home was part of the local community. The hair and beauty salon and café were open to the public.

People and relatives spoke positively about the home. One relative told us, “It is a modern way of looking at care; a lot of thought has been put into it.” All staff informed us they were happy working at the service and morale was good and they enjoyed working at the home. We observed that this positivity was reflected in the care and support which staff provided throughout the day.

Regular audits and checks were carried out to monitor all aspects of the service. Feedback systems were in place to obtain people and their representatives’ views.