Baycroft Flitwick

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 inspection we rated this key question good. At this inspection, 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. A learning culture was promoted at the service in ways such as staff handovers and meetings. Incidents and accidents were reviewed to see where lessons could be learned. People’s care plans and risk assessments were updated based on these reviews if necessary. Staff told us they discussed incidents and changed the way they supported people if necessary. One person said, ‘‘Staff are always on the lookout for me.’’ A relative told us, ‘‘I know the staff notice if things change and will sort things out. They made sure [equipment] was in place when [family member] needed it.’’

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. Staff supported people to access other services such as health appointments or attend services like hospital when they needed to. Staff shared important information about how people wanted to be supported with partners and professionals to help ensure safe transitions. One person said, ‘‘I have a health appointment today to check [health condition]. Staff have arranged all the transport and will make sure it all goes well.’’ A visiting health professional told us, ‘‘Staff notice when people need more support from us and get in contact straight away.’’

People were protected from abuse and improper treatment. Safeguarding concerns were taken seriously and investigated. The management team reported concerns to the safeguarding team where necessary and reviewed outcomes to see if lessons could be learned. Staff were trained in safeguarding and knew how to report concerns. One person said, ‘‘I feel very safe living here. No worries at all.’’ A relative told us, ‘‘[Family member] is 100% safe and is always very relaxed. When we go out, they always look forward to going back home to the service.’’

The provider worked well with people to understand and manage risks. Risk assessments and care plans were detailed and gave good guidance about how to support people to take risks safely. Staff knew how to keep people safe and no one at the service had experienced poor pressure area care or issues with their nutrition. We observed staff supporting people to use equipment such as hoists safely. Staff told us what they would do if they felt care plans or risk assessments needed changing. A person told us, ‘‘[Staff] know how to help me with everything I need. They are always slow and careful when I use [piece of equipment].’’ A relative told us, ‘‘[Family member] prefers to spend time in bed but staff always try and help them to get out and about and make them feel safe using [equipment]. They feel safer using this now.’’

The provider detected and managed all potential risks in the care environment. The environment was safe. Staff kept equipment people used safe and in good working order and carried out checks of the building to help make sure it was safe. Fire safety risks were understood by staff and well managed. One person said, ‘‘I love the feel of this place. My room feels like a home but it’s also a bit like a hotel.’’ A relative said, ‘‘One of the best things about the service is the way it looks. It is fantastic. I also know they practice fire drills as [family member] tells me what to do in an emergency.’’

The provider did not always make sure staff deployment was effective Some people went for long periods of time without meaningful staff engagement. Staff told us, and we observed, when staffing levels were lower than the rota stated, shifts were not always covered. Whilst staff told us they were able to support people safely, they also told us it impacted on their opportunities to engage with people throughout the day. A relative said, ‘‘It can sometimes be more difficult to find someone at certain times. It makes me wonder what happens when we are not visiting.’’ The management team responded to our findings by reviewing staff deployment throughout the day.

However, there were enough staff to support people with their needs such as personal care and eating and drinking and people and relative feedback confirmed this. Staff were knowledgeable about most areas they had training in such as moving and handling and supporting people to eat and drink. The provider recruited staff safely. One person said, ‘‘There is always a staff member walking around if you need anything.’’ A relative told us, ‘‘I would say there are plenty of staff. We always manage to find someone.’’

The provider assessed and managed the risk of infection. Staff were trained in IPC and told us they had the necessary equipment to keep the service clean. We observed the service to be visibly clean. Staff whose role was to keep the service clean took pride in their work and knew how important it was for people’s home to be kept clean. Audits and checks were in place to monitor the cleanliness of the service and the effectiveness of the IPC measures in place. A person told us, ‘‘It is beautifully clean here and [staff] all know us and have a laugh whilst they are getting on with their jobs.’’

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. For example, protocols and care plans for ‘as and when required’ medicines not being detailed enough and staff administering medicines being distracted regularly caused a heightened risk of medicine errors occurring. When found stocks of medicines differed from the audits being completed by staff, meaning medicines errors may be happening, but not being identified. A relative told us, ‘‘There have been a few medication errors, but they always let us know and tell us what they have done so it does not happen again.’’ The management team took immediate actions on our findings including retraining some staff and reviewing the auditing system in place for medicines.

Other areas of medicines administration were safe. People received their medicines on time and staff knew how people liked to be supported. Staff were trained to administer medicines and had their competency to do so checked regularly. One person told us, ‘‘I can trust the staff with all my medicines. I would not be able to do them myself.’’