Bales Court

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 Good. At this assessment, the rating has remained.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Following an incident in the service in 2024, the new management team had spent significant time making improvements to the service to ensure the quality and safety of the care provided had improved and lessons had been learnt. The manager told us, “If there’s an incident, we do a lessons learnt and a debrief form which all goes on to the system.” We reviewed the debrief forms which were detailed and demonstrated what remedial action had been taken to prevent reoccurrence of the incident. The manager gave an example of where lessons had been learnt and systems improved, saying “[Person] should have been positioned every 2 hours but staff weren’t recording it. I spoke to staff and the next day it was done. I think we’re investing in the home it will reflect on staff and people.”

Staff confirmed any improvements required after incidents were communicated with them and were having a positive impact in the service. One staff member told us, “There’s been an improvement recently for sure. Everyone has been on board and wants to make positive changes.” Another staff member said, “In our staff meetings, we discuss what has gone wrong and how we can work towards it and make it better. Staff can come out and speak to the manager. They are taking it seriously. Now they are on their toes with us and we are trying our best to make it right.” We observed staff meeting minutes from a meeting in January. Within this, discussions were had where the care being delivered could be improved. We found this had been implemented during our assessment.

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.

Regular fire drills occurred to ensure staff were aware how to evacuate people in an emergency. During a drill that took place in April 2025, it was identified that improvements could be made to this process, so action points to improve were discussed with staff.

‘Hospital passports’ were in place. These are documents that contain vital information about a person’s health, care, and communication needs that can be taken with them when they move to a different setting, such as a hospital attendance.

A new monitoring process had been introduced to ensure staff were completing daily checks of the premises in relation to fire and legionella safety. This was still being embedded with staff.

The provider worked with people and healthcare partners 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 shared concerns quickly and appropriately.

The manager told us, “The safeguarding policy has just been printed out and put in the read and sign book. We over-report concerns at the moment just to be safe while we re-establish the culture. The staff are my eyes and ears.”

Staff confirmed steps had been taken to ensure people’s safety at the service. One staff member told us, “We go on regular training for safeguarding so its refreshed regularly.” Another staff member said, “I would go straight to the manager and report any safeguarding. If the manager was involved, I would call the area manager and report it to them outside the company, I would contact CQC or anybody that deals with it.”

We were also informed that newly purchased security tags were being used on folders that stored people’s money. We observed these were in place and being used appropriately.

People’s rights were protected. We observed the principles of the Mental Capacity Act 2005 were discussed regularly in staff meetings to ensure staff’s knowledge of this topic was current. Mental capacity assessments were in place where people lacked the capacity to make decisions about aspects of their care, such as managing their medicines. Family members or professionals involved in people’s care had been involved in these assessments to ensure that any decisions made were in the best interest of the person and were the least restrictive option possible. One staff member told us, “It’s about people having capacity of what they want to do, but if they don’t then we have the best interests meetings for them and get the advocate and social workers.” The appropriate Deprivation of Liberty Safeguarding (DoLS) applications had been made to lawfully restrict a person of their rights where they lacked mental capacity. DoLS are important human rights safeguards; they aim to ensure that such deprivation of liberty only happens when it is necessary, proportionate and in the person’s best interests.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people were appropriately managed and mitigated. For example, one person required them to have a strict diet and regular weight monitoring due to a medical condition. We observed this was being followed in order to keep the person healthy.

People’s daily care notes recorded how much people had eaten and drunk throughout the day, and that they were being checked on regularly throughout the night to ensure their safety.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Our assessment took place due to an incident in 2024 in which unsafe levels of staffing was identified. However, we found no ongoing concerns in this area during our assessment. Staffing rotas demonstrated enough suitably qualified staff were on shift each day, and staff confirmed this was correct. Regular out of hours checks were being conducted by the management team to ensure night staff were on shift, deployed appropriately and completing their tasks. Agency staff were used to fill any gaps in rotas. Where possible, the same agency staff were used to provide consistency to people. A staff member confirmed, “We have enough staff here. We have 5 as standard and enough at night.”

On the whole, staff were up to date with their training. This included topics such as Oliver McGowan training, which is aimed at staff who require general awareness of the support autistic people or people with a learning disability may need. Where it had been identified that a staff member’s training was out of date in certain topics, action had been taken to book them on to the relevant training courses in the near future.

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.

Staff were observed wearing the appropriate personal protective equipment (PPE) such as gloves and aprons when appropriate.

The registered manager confirmed monthly infection prevention and control audits were completed. Any actions identified from this were resolved in a timely manner.

The provider did not always make sure that management of medicines was safe and met prescriber’s directions. However, action was taking immediately by the management team to address these concerns.

During our assessment, we identified protocols for as and when medicines (PRN) were not in place. This meant that staff may not know when these medicines should be given to a person. We received evidence from the manager immediately after our assessment that these had been put in place.

Medicine administration records for topical creams (TMARs) were not in place. This meant staff may not know where on the body the person’s prescribed medicated cream should be applied. Following our assessment the management team contacted a medical professional to clarify where topical creams should be applied for each person so TMARs could be put in place.

We identified a prescribed medicine was not on one person’s medicine administration record (MAR). This meant staff could not be sure the medicine had been given to the person at the times required. We also identified opening dates were not recorded on liquid medicines. The management team rectified these issues immediately when we informed them of this.

One person’s medicine was not being administered in line with the prescriber’s directions. The medicine was prescribed to be given to the person before eating food. However, we identified from the person’s MAR chart that it was being given to the person with the rest of their medicines, typically during or after they had eaten. This could have a negative impact on the efficiency of the medicine. The deputy manager informed us that this would be resolved immediately.

Temperature checks for medicine storage cabinets were not being completed regularly. Storing a medicine at a temperature higher or lower than the manufacturer’s instructions could affect the efficiency of the medicine. However, we did identify that when staff had identified the temperature in the cabinet was too hot, remedial action was taken by placing an ice pack on the cabinet to cool the temperature. The management team told us they would address this with staff immediately.

We were assured that all remedial action required was taken immediately following our assessment. However, further time was required to ensure the new processes were fully embedded with staff.

Staff worked towards the stopping over medication of people with a learning disability and autistic people (STOMP)initiative. STOMP is a national NHS England work programme to stop the inappropriate prescribing of psychotropic medicines. One staff member told us, “During [Person’s] psychiatric appointment, I asked if there is a way we can reduce their Olanzapine. They were always sleepy. So the psychiatrist reduced it. [Person] is more lively now. They spend time in the lounge with housemates, they like to go outside now. They are more settled now.”