Bede 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

The provider had an established quality assurance system which was used across all of its homes. However, this had not been effective in identifying shortfalls in recruitment records, person-centred care planning and medicines management.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Manager and staff knew about the provider's values and staff tried to work towards these. A staff member described how they approached their role to fulfil the values. They said this was, “For the residents to feel safe, happy and comfortable and make each day the best it can be for each person.”

The provider had a clear vision and set of values, aimed at providing high quality care for people and developing and valuing staff. The registered manager monitored the implementation of the values and provided feedback to staff, when needed.

The provider had a clear management structure for Bede House. Senior management attended the home regularly to support and guide the registered manager. The registered manager also had direct access to the Director Of Care and Chief Executive Officer, if required. The registered manager had development opportunities, such as completing ‘train the trainer’ courses.

Senior management gave positive feedback about the registered manager. A senior manager told us, “[Registered manager] is doing a good job and has improved everything in the home. She’s got a great relationship with residents, families and external professionals.” Staff also said had confidence in the registered manager. A staff member said, “Yes, I am 100% supported. [Registered manager] is amazing, guiding us and helping us massively. She is a great manger.”

Staff knew about the whistle blowing procedure and most staff were able to speak up when they had concerns. A staff member said, “ Yes 100% [able to speak-up]. Another staff member told us, “There's been a few things, as a team we have made suggestions and implemented them.”

The provider had a whistle blowing policy, which was reviewed regularly to help ensure it was current. Whistle blowing concerns were investigated and the findings used to make improvements to the care provided at the home.

Staff did not raise any concerns with us about equality and diversity issues. Most staff told us they had no issues with inclusion.

The provider had up to date policies and procedures relating to equality diversity and inclusion. Staff had completed equality and diversity training.

The provider had an established system of quality assurance, which was operated across all of its homes. The checks and audits we reviewed had been successful in identifying some areas for improvement. However, they had not been successful in addressing shortfalls in medicines management, recruitment records and person-centred care planning. The quality assurance system include a range of checks and audits in areas such as IPC, nutrition and pressure ulcers. The provider had implemented a new falls and incident tracker. This enabled managers to digitalise the approach to falls monitoring and enable live recording of outcomes, which could then be shared with staff to develop learning and better falls prevention. The provider's improvement plan identified areas for improvement and the progress made to address shortfalls.

Managers had a clear understanding of their role within the governance and management oversight of the home. This included operational oversight in areas such as recruitment, clinical support and compliance. Management had been involved in developing new monitoring systems and a home improvement plan.

People were supported to access the community as much as possible. People confirmed they had been shopping, visited the local pub and coffee mornings at the local church.

The provider had developed links and partnerships with the local community. This included people being supported to access the local community and to attend community groups, such as an art group. Staff had developed positive relationships with external professionals, intended to improve the quality of people’s care. This included the local district nursing team, specialist nurses, dietitians, speech and language therapists. The GP, the community elderly specialist nurse and other professionals participated in MDTs to review people’s health and care needs. The GP also carried out a weekly ward round. The registered manager had developed positive working relationships with the local authority commissioning and social work teams.

Most health professionals felt staff at Bede House worked well with community partners, including the local church and school.

Management and staff told us about the various relationships and links they had developed with partners and the local community.

Management and staff had a clear understanding of the positive aspects of the care provided at Bede House. They were also clear about the importance of learning lessons and had identified areas for improvement. These included further staff training and development, to care for people with mental health issues.

The provider's systems for identifying lessons learnt had not always been effective in addressing shortfalls in medicines and recruitment records. The provider was introducing ‘champion’ roles across the home in areas such as IPC, nutrition and wound management. The intention was for these key staff to promote best practice in their specialist areas. There were opportunities for staff to enrol on educational courses to enhance their skills and development and support career development. Some staff had been nominated for awards to recognise their achievements, for example one staff member was awarded for being a mental health ambassador. The registered manager worked in partnership with others to share good practice, such as in relation to nutrition and hydration and to roll out an integrated e-learning course.