Bakers' Villas

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good.This meant people were safe and protected from avoidable harm.

This service scored 72 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and information was shared to continually identify and embed good practice. Staff felt increasingly supported to reflect on their work and develop their skills. Although some incidents and accidents had not been reported at the time they occurred, managers recognised this and actively encouraged staff to strengthen reporting practices so learning could be shared openly. This supportive approach had begun to improve transparency, build staff confidence and ensure that learning from day-to-day events informed safer, more consistent practice across the service.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had effective systems in place to support safe care and maintain continuity for people as their needs changed. Staff worked closely together and with external professionals to ensure that information was shared appropriately and that people experienced smooth, well-coordinated transitions between different services. Daily handovers and clear routines supported consistent practice, and although some gaps in incident reporting had been identified, managers had taken steps to strengthen these processes so that risks could be better monitored and learning embedded. This approach helped promote safer care pathways and improved oversight of people’s wellbeing.

The provider worked with people and healthcare partners to understand what being safe meant to them and how best to achieve it. Staff focused on improving people’s lives while protecting their right to live free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. However, the provider had not always shared concerns quickly or appropriately.

The service promoted a safeguarding culture in which people felt protected from harm, and staff understood their responsibilities. People told us they felt safe living at Bakers’ Villas. One person said, “I feel very safe here; the girls look after me so well.” Another person told the Care Manager, “Tell them I am happy here and feel safe.”

Staff were able to describe the signs of abuse and the actions they would take, explaining they would “speak to management straight away,” and they felt confident to raise any concerns. Staff had received safeguarding training in line with the provider’s policies to support this.

We identified two incidents that should have been notified to the Local Authority and CQC. The registered manager responded immediately and submitted the notifications retrospectively. They told us they were fully committed to strengthening reporting processes to ensure concerns were shared promptly and learning could be embedded.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service had involved people in understanding and managing risks in ways that supported their independence and preferences. Staff told us they used risk assessments to guide safe practice. One staff member told us that they helped them understand “what the person can and can’t do” and how best to support them.

People also shared that staff always explained what they were doing and involved them in decisions, with one person saying the staff “always ask me first” before offering help. Although some documentation required updating, staff had worked with people to ensure risks were balanced with maintaining choice, dignity and control over day-to-day life. For example, while not all risk assessments were fully dated at the time of the inspection, the content remained accurate and reflective of people’s current needs, and staff could clearly describe the risks and the measures in place to manage them. This demonstrated that staff understood people well and were actively supporting them safely.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had maintained a safe environment for people, ensuring equipment, communal areas and individual flats were clean, well-kept and suitable for delivering care. Staff told us they followed clear routines to keep areas hygienic, and records showed that domestic staff supported this by cleaning both shared spaces and peoples’ homes. People described feeling safe in their surroundings, with adaptations such as bright lighting, accessible call bells and appropriate equipment helping them to remain independent. Where risks were identified, such as falls or issues with equipment, staff acted promptly, and the registered manager and care manager had begun strengthening oversight to ensure these risks were monitored consistently.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked well together to provide safe care that met people’s individual needs.

The service had a small but stable team with good knowledge of people’s needs, helping ensure care was delivered safely and consistently. Staff told us they worked well together and felt supported by both managers, commenting that they “get on well” and “always talk to management.”

Recruitment processes included DBS checks for all staff and new annual declarations to confirm ongoing suitability. However, we found a gap in one staff member’s employment history, some recruitment records lacked full verification, and supervision had not always occurred as expected. The registered manager was aware of these issues and had already taken steps to strengthen oversight.

Staff received appropriate training, including mandatory updates delivered online and face to face, and newer staff were supported through shadowing and hands‑on learning.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had maintained appropriate infection prevention and control practices to help keep people safe. Staff told us they wore the required personal protective equipment (PPE) during personal care, including gloves and aprons, and disposed of these correctly in line with expected procedures. Communal areas and individual flats had been kept clean through routine domestic support, and staff followed hygiene guidance such as disinfecting equipment like commodes after use. These practices helped promote a clean, hygienic environment and supported people’s wellbeing.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning their medicines, including when changes occurred. People told us they received their medicines safely and on time, with one person saying, “Yes, I receive my medicines on time every day,” and another sharing that staff often reminded them, “Don’t forget your medication.”

Staff were knowledgeable about peoples’ needs and followed clear processes for storing, recording and administering medicines. They had received appropriate training and guidance from managers to ensure medicines were handled in line with the provider’s expectations.

However, we did identify a concern regarding the timing of one person’s medicine administration, as doses on the medication administration record chart (MAR) were positioned too closely together, increasing the risk of side effects and reduced effectiveness. The care manager acted immediately by contacting the persons GP to request a medication review, after which the GP adjusted the administration times to ensure safer spacing between doses and more effective symptom management. This responsive action helped maintain safe practice and demonstrated the team’s commitment to continually improving the quality of people’s care.