Baily House

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 outstanding. At this assessment the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (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.

The registered manager and staff shared a common understanding of what good care looked like, and how they should work together to achieve it, and ensured good outcomes for people.

People told us the registered manager was open, transparent, and approachable. They felt confident that any concerns would be listened to and addressed promptly, which supported positive relationships between families and the service.

The registered manager fostered a supportive culture in which staff felt valued. Staff reported that they were able to provide feedback, raise concerns, and access support when needed

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The management team valued staff contributions and actively sought their views. Staff were supported with clear guidance, established procedures and relevant training to ensure they were confident and competent in their roles. They told us the registered manager was knowledgeable, and they felt assured the service was managed safely. Staff consistently described the registered manager as approachable, open, and supportive.

The manager told us they were proud of the staff team, and they felt supported by their management.

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

The service had policies and procedures that supported staff in speaking up. Policies included the topics of safeguarding and whistleblowing. The registered manager told us the service actively supported staff to speak up with any concerns or suggestions.

Staff told us they would have no hesitation to report poor practice and were confident action would be taken.

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 described an inclusive environment where equality and diversity were celebrated and promoted. Staff told us where management had supported them and amended working responsibilities when personal circumstances had changed.

They had also had a talk from the LBGT+ community, discussing this in older age. This resonated with staff and changed how staff spoke to people using the services and prevented assumptions being made. The manager reported positive changes and changes in the terminology staff used.

The provider had clear roles, responsibilities and systems of accountability that were well embedded and effectively used to deliver high‑quality, sustainable care. Leaders had strong oversight of risks, performance and outcomes and used accurate information to drive continuous improvement, sharing information securely and appropriately when required.

There were excellent quality audit tools in place at both registered manager and provider level. Audits were tailored to gain specific information that was meaningful and made a positive impact to the quality of people’s lives. A comprehensive programme of service-wide audits and performance reviews included regular review of care records, medicines management, infection prevention and control, care plans, staff development, and people’s experiences of care. Audit outcomes were analysed and acted upon swiftly, with clear action plans. Any areas for improvement were identified in audits and were promptly shared with staff to support learning and improvement.

A dedicated quality assurance team provided additional oversight, ensuring compliance with mandatory documentation and analysing themes and trends across all services. Learning was shared organisation‑wide to improve practice. The provider also demonstrated innovation by developing a bespoke governance system tailored to their needs, which is being implemented to further strengthen audits, action planning and sustainability.

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 were processes to ensure partnership working with people, relatives and health professionals was maintained to improve people's experiences, health, and wellbeing. The registered manager told us of the positive impact a weekly ward round had with external professionals at Baily House. They told us “Having them all there means people get a quicker response and referrals. Having them in house has been a really good thing.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They considered and reviewed the quality of experience, outcome for people living at the service.

Leaders ensured they continued to learn and improve their services. Best practice and examples of what had worked well were shared amongst the team.

Accidents and incidents were analysed to look for trends and themes to prevent re-occurrence. Improvement plans were in place considering all aspects of service delivery. Actions were recorded and followed up. There was an open and honest culture within the home fostered by the management team. Improvement plans were realistic and had considered all the feedback they received from people and relatives.

The internally developed quality assurance system ensured consistent improvement within the system.