Bainbridge Court

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 Good. At this assessment the rating has remained 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 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. Leaders showed a focused approach in ensuring people received good quality care.

There was a focus personalisation, providing control for people, collaboration with others in care and positive support. These values and shared direction matched the providers statement of purpose for Bainbridge Court. Leaders were knowledgeable about issues and priorities for the quality of care of the service. One professional said, “Bainbridge worked closely with the family of the person I was supporting to ensure they were included at all meetings and were fully involved for the plans for this person.”

Staff completed Equality and Diversity learning as part of their core training. Ethnicity, religion and sexual orientation were captured within people's care plans. Records showed that consistent and regular supervisions were undertaken, while staff meetings were held so staff could provide feedback and contribute. Managers and staff understood the diverse needs of the people they supported.

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.

Leaders were alert to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff. For example, robust quality assurance systems and a consistent reviewing of people’s support, restrictions and outcomes ensured that changes in need were identified and implemented quickly.

Staff, relatives and professionals spoke positively about the leadership of the home. They spoke of a culture of inclusiveness and collaboration to ensure everyone was involved in people’s support. One relative said, “(Manager) seems very well versed in everything. I’m positive about the future. It’s going well.” One professional said, “The team collaborated effectively to comprehend the messages conveyed by the individual during the presentation.”

Leaders encouraged an open service and office where staff could raise any issues about care and their roles. The provider fostered a culture with staff where they felt safe to raise issues, express any concerns and communicate effectively with the leadership.

Systems and processes were in place to enable staff to raise concerns anonymously if they wished. The provider had a detailed and thorough policy guiding staff on raising concerns, detailing pathways to speak up freely and for whistleblowing.

Staff we spoke to felt comfortable raising issues and contributing to peoples care and support. Staff involvement in PBS meetings supported this. Leaders were open and accessible to staff and spoke warmly about individual staff members, their strengths and development within Pathway Healthcare. One worker said, “I do feel it's well run because the communication is good. You can raise any concerns and get the answers that you need. I believe it is well run.”

The leadership team were clear and proactive on the approach to staff inclusion and equality, acknowledging with a workforce of staff who came from diverse backgrounds. Staff had received Equality and Diversity Training as part of their training within the service.

The provider had policies and procedures in place to create an inclusive environment that upheld the principles of equality and diversity. The provider was aware of their duty as an employer, to understand and respect people’s protected characteristics and prevent discrimination.

The provider ensured that protected characteristics of staff were considered as part of this approach. Staff were afforded flexible working arrangements to accommodate religious festivals and practices. Staff spoke positively about the management team and voiced no concerns.

The provider was actively recruiting for a new registered manager at the time of the inspection. However, the provider had ensured that there were clear and effective management and accountability arrangements. An experienced manager within Pathway Healthcare was overseeing the home, supported by the operations team. The manager had a good knowledge of the people and staff at the home.

The provider had robust and effective systems in place to manage the current and future performance. Quality assurance checks and audits were regularly conducted by staff at the home and by the providers’ operational and compliance teams. Incidents were analysed and reviewed to ensure that a proportionate approach was taken to risks. Care compliance audits, safeguarding reviews and risk indicator meetings were completed to review the quality and safety of care being delivered. Operations staff and leaders consistently reviewed actions plans to ensure that issues or development were being addressed.

The provider understood their regulatory responsibilities. A review of statutory notifications completed prior to on-site assessment confirmed that they complied with the process for reporting to local authorities. Management ensured that they, and care staff, understood their responsibilities relating to people's information, records and confidentiality.

The provider understood their duty to collaborate and work in partnership. Staff and leaders collaborated with partners and professionals in care, and shared information to ensure effective joined up working. Appropriate referrals for specialist and health support were made where relevant and needed. One professional said, “Partnership working with Bainbridge was good, they always attended our regular network meetings we were having for the person I was supporting.”

Professionals spoke positively about the partnership approach of staff and leaders at the home. One professional said, “The key worker, home manager, and service manager participated in MDT meetings and other professional catch-up sessions as we collaborated. The staff demonstrated compassion. The key worker attended the MDT meeting on their day off voluntarily. A staff member who had developed a good rapport with the individual began collaborating with other team members to share the knowledge they had gained regarding the best ways to support the individual and their insights on effective engagement.”

The leadership had shown a consistent and positive approach to improving the quality of care. For example, leaders and staff worked closely with the provider’s positive behaviour support team to consistently review people’s support and implement any learning. One professional said, “We worked together to identify some of the reasons behind why the person was having difficulties and worked in partnership to think about how best to make improvements.”

Robust and consistent quality assurance systems and audits had been used to identify issues, and learning was used to drive service improvements and people’s experiences. Processes were in place to ensure learning when things go wrong. Systems were in place for staff to report and record any accidents and incidents, while appropriate actions had been taken for each event.

Staff spoke positively about the providers approach to developing staff and encouraging them to develop. Staff spoke about development training that they were undertaking to improve their knowledge. One team leader said, “They offer development programmes for team leaders and management. They recruit internally for these. I did my level 4 and doing my level 5. I get the support of my managers.”