Baycroft Flitwick

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 inspection we rated this key question requires improvement. At this inspection, the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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 and management team had a shared vision, strategy, and culture. However, the culture at the service was not always positive. The management team wanted what was best for people and had the quality of their care and support as a clear aim and value. However, in practice some staff practice was not person centred. For example, people went for longer times without meaningful engagement or staff did not always treat people in a supportive way as described in the ‘Kindness Compassion and Dignity’ and ‘Treating people as individual’ quality statements. Some staff still felt unsupported in some areas of their work. The management team were aware of these issues and had plans to continue to improve the culture of the service.

However, people and their relatives were positive about their support at the service. One person said, ‘’I could not live anywhere else. Everything I need is right here.’’ A relative told us, ‘‘[Family member] absolutely loves it at the service. Whenever we see them, they are so bright and full of stories about what they have been doing.’’

The provider had inclusive leaders at all levels who understood the context in which they delivered care and support. They did so with integrity, openness, and honesty. The management team were an active presence at the service, spending time with people and staff. They had reacted to some of the known issues at the service and had made sure management team were on hand to support people, relatives and the staff team. They listened and took feedback seriously. As a result, people and the staff team felt included in discussions about the running of the service. Overall, staff felt well supported by the management team. People and relatives told us the management team were kind and caring. One person said, ‘‘I see [management team] and they are always here if you want to speak with them.’’ A relative told us, ‘‘The management team are a part of the staff team. We can request to speak with them whenever we need to.’’

The provider fostered a culture where people felt they could speak up and their voice would be heard. Staff knew how to speak up and raise concerns and told us they would feel comfortable doing this. People and relatives knew what to do if they needed to make a complaint and were assured that these would be investigated and taken seriously. The management team kept a record of concerns and made sure people were responded to with a resolution and any changes that would be made as a result of the concern being raised. One relative said, ‘‘I have raised a concern before and was happy with how this was responded to.’’

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. However, a number of staff did not feel as supported as they wanted to whilst working at the service. The majority of these concerns had happened over previous months where staff had not been receiving effective support or being given the opportunity to speak to the management team regularly. Staff also felt staffing levels when colleagues phoned in sick were not being covered effectively. Staff also told us there had been improvements in these areas more recently, however these would need more time to embed. The management team told us they were aware of these issues and were actively working on improving them. The provider’s recruitment process was fair and equitable.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Whilst measures were now in place to audit and measure the quality of the service and most of these were effective, this was as a result of a lot of input from senior managers. Before this input, there had been numerous issues at the service including medication errors and poor monitoring of incidents and accidents. Despite audits now being put in place, they had still not picked up on some of our findings at this inspection. For example, in relation to medication practices, amendments needed to some care plans and people not always being supported in line with their preferences or going long periods of time without meaningful engagement. However, audits and governance measures put in place by the senior management team had proven to be effective in starting to identify and address issues.

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.People saw health professionals if this was needed. Visiting professionals were positive about the staff team and how they worked with them. The management team worked well with partners such as the local authority. Staff supported people to places of interest in the local community such as cafes. One person said, ‘‘I like to be busy and there is always somewhere we can go if we want to.’’ A relative told us, ‘‘The activity staff team are brilliant. They have a great program of stuff to do, and they are always full of smiles and happiness.’’

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider and management team were keen to improve at the service and took our feedback seriously. However, there were still some areas of the service that needed further improvement. Whilst the senior management team had been effective in identifying and driving some improvements at the service, more time would be needed to make sure the improvements were sustained.

Despite some of our findings, the staff and management team always looked for improvements and ways to help people have the best experiences of support they could have. There had been significant improvements in known areas over recent months. One person said, ‘‘We can say if we are not happy and staff will work hard to change things.’’ A relative told us, ‘‘There has been a lot of things going on at the service recently and [management team] seem to be making a lot of effort to make thing better.’’