Bayview Healthcare Limited

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.

This is the first assessment for this newly registered service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 63 (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 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.

The provider was keen to engage and learn from the inspection. When we identified concerns, they responded quickly and took action to improve. For example, they updated care plans and risk assessments when we identified they contained conflicting information. The provider viewed feedback as an opportunity to learn and put things right.

People, staff and relatives told us they knew how to raise concerns if they needed to.

There were policies and procedures for managing safety events and following the inspection, the provider submitted an action plan of intended improvements.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

Systems and processes to share information between services were not always robust. For example, when people were admitted to hospital, including unplanned admissions, staff and people verbally handed over important information. However, this did not consider where a person’s condition could mean they were unable to share, or staff may not be able to recall in an emergency. Following the inspection, the provider told us they planned to introduce hospital passports and a grab file to ensure essential information would be immediately available to share.

Systems and processes for communication and information sharing with other services involved in people's care were not always effective. For example, care plans were not shared, and there was no established regular communication process between the services. Although, the provider told us carers would share information between the services, daily records did not reflect this taking place. People and their relatives said they were happy with the support they received. Following the inspection, the provider submitted an action plan which detailed the action they would take to improve communication with other services involved in people’s care.

Before delivering care, the provider assessed people’s needs, which included requesting information from services such as the local authority.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve it. 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 shared concerns quickly and appropriately.

Staff had the knowledge, skills and training to protect people from harm and abuse and knew how to identify, respond to, record and report safeguarding concerns.

A person told us they felt safe when supported by staff and had positive relationships with them. Relatives and professionals spoke positively about the service and told us they had no concerns with the care provided.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We could not be assured people were always protected from the risk of pressure injury. For example, records showed a person assessed as at risk of skin breakdown had not been supported to reposition in line with their care plan. Following the inspection, the provider submitted an action plan which detailed the action they would take to improve repositioning recording.

Although care plans and risk assessments generally contained information staff needed to know to support people, there were some inconsistencies between documents. For example, records were not always consistent and contained conflicting information about people's needs and health conditions. Although staff demonstrated knowledge of people's needs, the provider could not be assured that accurate information was always available to support safe care.

When we raised this with the provider, they updated the care plans to include the relevant information.

Other risks to people were assessed and mitigated, and we saw concerns were escalated to healthcare professionals when needed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Environmental risks were assessed and mitigated to reduce the risk of harm to people. For example, a Personal Emergency Evacuation Plan (PEEP) was in place which explained the support a person needed in case of emergency, and risks within a person’s home environment were assessed and reduced. Feedback from other professionals indicated staff ensured environmental risks were well managed.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support, supervision and development. They worked together well to provide safe care which met people’s individual needs.

The provider did not always ensure staff were recruited safely. Although there was a recruitment policy which identified procedures for safe recruitment, 2 staff recruitment files did not contain a small number of pre-employment records, which meant the provider could not be assured suitable staff were employed to work with people who use the service. However, after we raised this with the provider, they completed the checks.

Staff did not always have the right skills and knowledge to support people safely. For example, staff did not initially receive training to support a person with their specific needs. When we raised this with the provider, they took immediate action and staff received this training. Staff completed other training such as moving and handling, first aid, infection prevention and control (IPC) and food hygiene.

Staff were well supported by management. There was an induction process to support new staff, and they benefitted from regular supervision from leaders, who used these to support them to learn and develop in their roles.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were protected from infection. Staff had access to and used Personal Protective Equipment, (PPE) and completed Infection Prevention and Control (IPC) training. They had the knowledge and skills to reduce the risk of infection and were guided by policies and procedures.

One person told us they were very happy with how staff managed infection prevention and control in their home.

The provider did not always make sure that medicines and treatments were safe and met people’s needs. Staff involved people in planning, including when changes happen.

Medicines records, care plans and daily notes did not always contain consistent information. For example, prescribed medicines dose and administration times were sometimes recorded differently across records. This increased the risk of medicines errors.

We found people did not always receive medicines when they should. For example, when a medicine needed to be administered at a specific time or have a specific time between doses. When we raised this with the provider, they took immediate action to ensure people received their medicines as prescribed.

When people were prescribed medicines ‘as required’ (PRN), there were not always protocols to give staff clear guidance about when to administer the medicine, and staff did not always record the reason the medicine was administered. This meant there was a risk people could receive medicines unnecessarily or incorrectly. When we raised this with the provider, they reviewed the medicines with the person’s GP and put PRN protocols in place.

Staff did not always record when they applied people’s topical creams. This meant we could not be assured they were administered as prescribed.

Despite shortfalls identified, we did not find evidence of harm to people, and people and their relatives were happy with how staff supported them with their medicines. The provider had a positive and effective relationship with healthcare professionals and demonstrated they could address concerns quickly and effectively.