Bayith Rest Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. The service was in breach of legal regulation in relation to the governance of the service and records.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

People, relatives and staff told us there was an open and caring culture at Bayith Rest Home, where people came first. The service was frequently described as “like a big family”. People were happy living there and staff enjoyed their work. The manager and staff demonstrated a commitment to providing person-centred, high-quality care. Staff spoke of the satisfaction they gained from making a positive difference to people’s life.

Leaders had not always had the skills, knowledge, experience and credibility to lead effectively.

We identified some concerns in the service, as detailed in the Safe domain of the report. The nominated individual told us action was taken when they identified a previous manager was not meeting the expectations of their role. This went some way to demonstrate the effectiveness of the leadership. However, we were not assured all the issues could be attributed to this such as some of the environmental and infection control concerns. The new manager had only been in the service for approximately 2 weeks and although told us of the improvements planned, needed the time to make and embed these. Staff and people provided positive feedback about the new manager and were confident they would do a good job. Staff also told us the nominated individual was approachable.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were aware of the whistle blowing policy and knew the procedure to follow. Staff said they would speak with the manager about any issues and were confident they would be listened to, and issues acted on.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt valued and respected at work. The provider’s recruitment procedures considered people’s equality, diversity and inclusion. The manager provided examples of being inclusive, and showed passion about upholding rights, regardless of protected characteristics. For example, ensuring and supporting staff to access training regardless of disability so everyone had equal opportunities to progress.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

There was a quality assurance process with a range of audits, including: medicines management, infection control and care plans. In addition, an external consultant had conducted an audit to support the home achieve compliance. However, the systems were not always effective in monitoring quality and driving improvement. For example, with care records, the environment and monitoring outcomes for people.

The manager had plans to improve and told us the provider was supportive in making these. However, a service improvement plan had not yet been implemented. Information was shared as needed with other agencies. This included statutory notifications as required by CQC.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

There was an effective system to ensure partnership working with health and social care professionals, and local partners. Referrals were made to other professionals when needed. When professionals provided advice and guidance, this was followed by staff. Processes such as handovers meant staff understood people’s changing care needs.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

The provider did not have a clear process to focus on continuous learning and improvement from events, audits and information across the service. It was not always clear from records what learning was taken from accidents or incidents, or what improvements had been made from audits.

The manager acknowledged the shortfalls identified during this inspection and told us they had plans improve. The manager told us they would implement a service improvement plan after our visit. Staff had team meetings to discuss the running of the service and told us they were listened to, and their feedback was taken on board. The manager had an open-door policy and told us they welcomed feedback to support the service. The manager shared some success stories to note how they supported people to improve their health and wellbeing that positively affected their lives.