Baily House

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 69 (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 investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People told us they felt able to raise concerns with the management team and felt listened to. They were confident any issues raised would be acted upon.

Any learning from safety events was always communicated and acted on. The registered manager showed us lessons learnt logs and explained that these were shared with staff. The changes were also discussed during staff supervisions and team meetings to reinforce learning and promote consistent practice.

The provider had looked at reports for other locations, or incidents from their sister home in order to reflect on other practice. They used this to implement changes following reflective practice.

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 worked with people, and those close to them, to establish their plan of care and comprehensive individual transition plans, prior to the person moving between services to eliminate any risks and to ensure the person received continuity of care.

The provider told us they carried out preassessments which included meeting the person and their family. They gathered information from health professionals or social care to further inform the assessment process. There was a resident liaison in the home who met people when they first came to stay at Baily House and help them settle in.

The service had a ‘resident of the day’. This meant they focused on ensuring care plans were reviewed for all residents regularly. They used this time to gather feedback regarding any particular meal requests or preferences on activities.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider had effective procedures in place to protect people from abuse. Staff told us, and training records confirmed, that they had received safeguarding training and understood their responsibilities. Staff said they felt confident that any concerns they raised would be taken seriously and managed appropriately.

People living at the service told us they felt safe. One person told us, “Oh yes, I’m perfectly safe, all the carers have got empathy, they are very good, also the cleaners, they have time to chat”.

People were supported to understand information, communicate and make decisions about their life, care and treatment in line with the Mental Capacity Act (MCA). People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through the Deprivation of Liberty Safeguards (DoLS), which is part of the MCA. We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service and found where needed people had DoLS authorisations in place. The provider followed the principles of the MCA when people needed to make decisions and had systems in place to track and monitor when a DoLs authorisation was in place.

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 provider worked with people to understand and manage risks in a holistic way. Staff delivered care that was safe and supportive while enabling people to take positive risks. Risks relating to people were assessed and managed appropriately, with the involvement of the person, so they understood any decisions about this. For example, we observed one person had a stairgate on their bedroom door. The person told us this was their choice. They explained the reason for this and showed us they could open and close it themself. There was also a risk assessment in place regarding the gate being in place.

People also had personalised emergency evacuation plans, which detailed the level of support they would require to evacuate the building safely in the event of an emergency.

When people communicated their needs, emotions or distress, people were supported, and staff could manage this in a positive way that protects their rights and dignity. Appropriate strategies were used to minimise the need for restrictive interventions. We reviewed care plans which reflected how best to support people in times of distress.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the assessment, we found window restrictors were not always in place. We found topical creams were not always stored safely and were found in cupboards, which were not labelled with open or disposal dates. We found staff used a communal sling to support people who required the use of a hoist, rather than personalised slings which meant there was a risk of people falling or injury and at risk of infection from cross contamination. We also found prescribed drinks in an unlocked cupboard in a communal kitchen where people living at the service had free access, and pressure cushions which were not named and some required disposing of. We raised these concerns with the registered manager who took immediate action and provided assurances.

There were health and safety checks in place which were up to date, which showed the equipment had been checked, was compliant and in safe working order.

The provider did not always make sure there were enough qualified, skilled, and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

There was a tool used which established required staffing levels based on people’s needs. Rotas and staffing levels were in line with this. However, during the assessment, we observed communal lounges to be left unattended with people present and unable to gain support if required. We observed one person asking for help and was told they had to wait.

People living at the service and their loved ones told us they did not feel there were enough staff. One person told us, “Yes [more staff] I think the floor we’re on could be better.” A relative also told us, “They seem very short staffed.”

Professionals also provided feedback on the service. When discussing how responsive staff are, one professional told us, “Some staff seem to be better than others, it is inconsistent. On occasions the lack of responsiveness has led to delays in obtaining the information that I need and then staff acting upon advice/plan.” Professionals also commented that they felt the home was short staffed.

Staff were safely recruited and are provided with opportunities to develop and learn.

The service demonstrated clear infection prevention and control practices. Infection risks were assessed, and effectively managed to prevent spread..

During the assessment, we found slings were moving and handling were shared which posed as a risk for infection control. This was raised with management and assurances provided that this had been addressed with staff.

Clear infection, prevention and control (IPC) roles, responsibilities and procedures were embedded across the service. Information about infection risks and control measures were shared with staff, people using the service, visitors, and external partners. People were supported to understand and follow IPC measures in a way that promoted safety, dignity and choice.

Strong leadership was provided by a dedicated Head of IPC, whose work was recognised and shared across the wider care sector. They actively supported other care homes and had offered mentoring to new IPC leads to showcase best practice which included tours of the service to see the IPC systems in place.

Staff were actively engaged in maintaining high IPC standards, with domestic “IPC champions” leading on specific focus areas. Practices were personalised, with staff aware of individual needs such as sensitivities to laundry products. Robust cleaning rotas ensured high standards of cleanliness.

We viewed people's ensuites and found them to be spotlessly clean, with a toilet, washbasin and walk in shower.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and in line with prescribed guidance. Medicines were administered by trained staff who had completed up‑to‑date medication competency assessments.

Medication administration records (MARs) were completed accurately, with clear staff signatures, and reasons for medicines not being administered were recorded. ‘As required’ (PRN) medication protocols were in place and provided clear guidance for staff on when and how these medicines should be administered. Medicines were stored securely in locked cabinets within the service. Controlled drugs were stored in dedicated controlled drug cupboards and managed in accordance with regulations.

The management team carried out regular audits of medication practices to ensure they remained safe and effective.

People and their relatives told us they had no concerns regarding medicines administration and they received them on time.