Bailey 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 requires improvement. At this assessment the rating has changed to 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.

Staff recorded information about accidents and incidents, and these records were reviewed by the registered manager to identify any action required to reduce the risk of similar incidents occurring again. We noted staff were not utilising the provider’s electronic care recording system to its full potential to complete accident and incident records. Better use of the system would help management more easily track themes and learning from incidents. The registered manager said they would raise this with staff immediately and implement improvements to the process.

Staff confirmed they could discuss any lessons learned from incidents as a team and with the registered manager.

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.

Appropriate referrals were made for healthcare support where required. A visiting professional told us they had good working relationships with service and staff followed their guidance.

If anyone needed to go into hospital the provider had a system to ensure key information was readily available to share, to assist in the continuity of people’s care and wellbeing.

The provider worked with people 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 had a safeguarding policy and staff completed regular safeguarding training. Staff were aware of the signs of potential abuse and understood what action to take if they had any concerns. The provider made safeguarding referrals when required.

Applications had been submitted to lawfully deprive people of their liberty where this was required. Staff adhered to any conditions on people’s Deprivation of Liberty Safeguards authorisations. This ensured any actions were the least restrictive and in people’s best interests.

The provider had made improvements in the management of risk since our last assessment. Risk assessments were now in place and were regularly reviewed. They covered a range of risk areas for each person, such as falls and nutritional risks.

Staff demonstrated good understanding about potential risks relating to each person and followed the risk assessments in place. We saw staff were attentive to people’s safety and wellbeing, including when supporting people with activities like preparing meals.

Relatives felt people were safe and we observed people appeared comfortable within the home. A relative told us, “I believe he’s safe there.”

Staff understood when people communicated distress or anxiety through their noises and non-verbal communication. They responded promptly and always took the least restrictive approach.

The provider completed regular checks of the property and equipment to detect potential risks in the care environment and support the delivery of safe care. The property was generally well maintained, and any maintenance issues identified were reported to management so they could be rectified. Most of the actions identified in environmental audits and fire safety checks had been completed. However, on the first day of our assessment we found three fire safety issues identified in audits that had not been addressed. The provider completed these promptly following our feedback. Improvement was needed in relation to communication and oversight of safety and environment checks, to ensure all issues were promptly addressed moving forwards.

Since our last assessment, the provider had developed the outside area at the rear of the home, so there was now a pleasant and secure outside seating area for people to enjoy. The registered manager told us they intended to add more sensory features in this outdoor area. They also planned to develop a spare room in the home into a sensory room to provide an additional calming, sensory environment.

The provider made sure there were enough qualified, skilled and experienced staff, who received support and supervision. They worked together well to provide safe care that met people’s individual needs. Staff told us that if someone was unexpectedly absent due to illness for instance, other team members would step in to provide cover, meaning agency staff were not required.

The provider had made improvements to recruitment practices and was now meeting legal requirements in this area.

Staff were satisfied with the training they received and said they could ask for extra training and support if they needed it. The registered manager monitored training compliance and prompted staff to complete their refresher training when this was due. Staff had received training in supporting people with a learning disability and autism, but the registered manager was still in the process of sourcing more advanced training in this area, in line with the new mandatory learning disability training requirements.

The provider had made improvements in relation to infection prevention and control practices since our last assessment. They now assessed and managed the risk of infection appropriately. The provider detected and controlled the risk of it spreading and had systems in place to share concerns with appropriate agencies promptly.

The environment was clean and infection prevention and control policies and procedures were in place. Staff completed training and competence checks in this area. The provider also completed handwashing audits. We observed staff using personal protective equipment (PPE) appropriately.

People were given their medicines safely and in a timely manner. This was recorded on their medicines administration record (MAR) and medicines were stored safely and securely. There were processes in place to ensure the safe and effective use of medicines. However, instructions for medicines which should be given at specific times were not available. Body maps were not in place for topical creams and ointments, to show staff the site of application. The provider addressed this straightaway.

Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as ‘PRN’, was available to staff. Where people were prescribed medicines with a variable dose, the quantity given was recorded. This meant that records accurately reflected the treatment people had received. We checked the quantities and stock balances for two people and found them to be correct.

There were records of people’s preferences to indicate how they wanted their medicines to be administered. Temperature records to ensure the safe storage of medicines were completed following national guidance. Records showed that management or staff carried out regular medicines audits. Staff had received medicines handling training, and their competencies were assessed regularly to make sure they had the necessary skills. There was a process in place to record any medicines related errors. Some people had a different routine, and this was accommodated to ensure they were kept safe.