Bailey 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 inadequate. 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 68 (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 vision and values statement, but staff were not familiar with this and couldn’t consistently describe what the shared vision and values of the service were. However, staff feedback indicated there was a generally positive culture, focussed on ensuring people were well cared for and had a good quality of life. One staff member said, “[Register manager]’s motto is: ‘We work in their home’. We always need to be respectful and promote their wishes and independence.”

Staff enjoyed working at the home. Staff told us, “We've got the chance to be so personal here and do everything that people want. That's the advantage of it being such a small service.”
 

The provider had inclusive leaders who understood the context in which they delivered care and support and embodied the 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 registered manager was responsible for managing two small services in the same town, including this one. They knew people using the service and staff well. Relatives provided positive feedback about the management of the service. One commented, “[Registered manager] is lovely. It seems well-run.”

Staff felt supported and confirmed they were able to contact the registered manager or team leader if they ever needed it. A staff member commented, “You're never left not knowing what to do. When you work as a team it makes it better for us and the service users... [Registered manager and team leader] are approachable.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Information about whistleblowing and how to report safeguarding concerns was available to staff. They told us they understood the processes for raising issues and felt able to speak up without hesitation. Staff were confident the registered manager would take any concerns seriously and act on them promptly, which supported an open and transparent culture.

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.

The provider had recruitment, selection, and equality and diversity policies designed to promote a fair, inclusive and non‑discriminatory workplace. Staff wellbeing was actively supported, and team members reported feeling well supported by the registered manager. This contributed to a positive and inclusive working environment.

The provider had taken action to improve governance and auditing arrangements since the last assessment, and they were no longer in breach of legal requirements. The registered manager carried out a range of regular audits, and these resulted in action being taken when shortfalls were identified. However, during our assessment we found some issues that had not been detected through existing audits, including fire safety concerns that had not been addressed promptly.

The provider usually submitted required information to CQC in a timely way, about relevant incidents at the services. However, we found the provider had inadvertently missed one submission. This notification was sent retrospectively. This meant there was a delay in CQC being able to review the information to ensure the matter had been dealt with appropriately.

Some of the provider’s audits needed to be more robust, as they were repetitive and did not always give detailed feedback. This was important because the registered manager often audited care plans and records they had written themselves. Additional independent oversight from the provider would offer more objective scrutiny, support the registered manager and help ensure regulatory requirements were met in a timely way.

Although governance had improved, further refinement was needed to ensure systems operated fully effectively.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement.

The provider worked with a range of health and social care professionals to ensure people’s health and wellbeing needs were met, which led to positive outcomes. A visiting health professional told us they worked well with the service, and staff were responsive to the guidance they provided. The home was located in a residential area and there were facilities in the local community. One person regularly went to the local club and was known to people there. Their relative told us how much they enjoyed living in the area, which they knew well.

The provider focused on continuous learning and improvement across the organisation. They encouraged creative ways of delivering a good quality of life for people and contributed to safe and effective practice.

The provider had learned from the previous assessment and made improvements. The registered manager promoted a culture of openness and encouraged staff and others to share new ideas and suggestions. They used information from incidents and audits to identify learning opportunities and enhance practice. They were also receptive to our feedback on improving how accidents and incidents were recorded. A staff member told us, “[Registered manager]has done a fantastic job of getting us back on track.”

The registered manager explained they kept up to date with best practice and legislative changes by reviewing relevant websites, guidance updates and regulatory bulletins. We discussed the value of seeking additional peer support and engaging more with other providers, as this could further strengthen best‑practice knowledge, continuous improvement and innovation.