Bayview Healthcare Limited

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.

This is the first assessment for this newly registered service. This key question has been rated 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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Although there was no registered manager in post, there was a clear management structure which staff and people were aware of, and the provider told us recruitment was ongoing for a new manager.

The service had clear values which were upheld by the staff and was reflected in their work with people. Staff demonstrated an understanding of equality, diversity and human rights in their approach to care.

Staff and leaders demonstrated a positive, compassionate, listening culture which promoted trust and understanding between them and people using the service. The provider was focused on learning and improvement, and demonstrated they were keen to respond to and learn from concerns raised during the inspection.

Leaders worked effectively together to share information. Meeting minutes demonstrated formal discussions about the service and set actions to be completed between the provider and the previous manager.

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. They did so with integrity, openness and honesty.

The provider ensured there was suitable management cover in place while they recruited a new registered manager. There was an open and honest culture, where learning was embraced without blame. Leaders understood their responsibilities, and where shortfalls were identified during the inspection, they implemented improvements, including systems to proactively identify shortfalls.

Staff received an induction and were well supported. They received regular, effective formal and informal supervisions, and had access to staff meetings to support them. When improvements were identified, managers met with staff to discuss changes and create action plans with them.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. There were formal and informal opportunities for staff to speak up, and they told us they were confident their voices would be heard. There was a culture where staff felt confident to speak up and raise concerns without fear of detriment.

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.

Staff told us they felt well supported by the management team. They told us rotas suited them, considered their needs and they were treated fairly and equitably.

All staff were given the opportunity to nominate other staff for recognition and reward.

The provider did not have good governance systems and processes in place. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not have effective systems and processes for quality assurance in place. A provider audit, completed 9 months before our inspection, identified actions that had not been completed by the time of our inspection. For example, the audit identified a need for medicines competency checks and training. We continued to find shortfalls in these areas during our inspection.

The provider told us due to the size of the service, audits were completed on a more informal basis, such as by reviewing care plans. However, these were not always effective. For example, they did not identify shortfalls found during our inspection as detailed in the ‘Involving people to manage risks’ quality statement of this report

The provider did not have effective oversight of staff skills and training. Training records were not always accurate or complete such as, IPC and food hygiene. As a result, gaps in training needs were not consistently identified or addressed, increasing the risk of people being supported by staff without the necessary skills and knowledge.

Following the inspection, the provider submitted an action plan which detailed the action they would take to improve their oversight of the service. This included formalising and increasing the frequency of audits, reviewing and updating audit documentation, and having named staff responsible for overseeing these.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider did not always have effective systems and processes to facilitate joined up working with other services. For example, with a service who worked alongside the provider to support a person. Following the inspection, the provider submitted an action plan which detailed how they would improve communication with other services.

However, people, relatives and staff told us they felt the provider worked effectively with other professionals such as, with community healthcare professionals, pharmacy and GP.

Professionals were also positive about the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

Although there was a culture and willingness to learn and improve, systems and processes were not always effectively established to identify improvements. When issues were identified, actions were not always completed or their effectiveness evaluated.

The provider told us systems and processes such as quality reviews were not always in place due to the current size of the service. Following the inspection the provider submitted an action plan which detailed how they would implement learning from the inspection and embed internal review and auditing systems.