CQC report explained · a residential care home
What the CQC found at Bayis Sheli Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that medicines, recruitment, infection control and risk management were handled safely. Staff knew how to protect people from abuse and respond when people became anxious or distressed.
- Effective?
- Good
- This question was not assessed during this focused inspection.
- Caring?
- Good
- Staff used respectful communication and supported people's dignity, privacy, choices, religious needs and independence. Care records described people's preferences and support needs in a person-centred way.
- Responsive?
- Good
- This question was not assessed during this focused inspection.
- Well-led?
- Good
- The manager and provider had a clear vision for the home and used audits to monitor care. Relatives said managers were approachable and that they could raise concerns.
What inspectors found, August 2022
Rated Good; inspectors found safe, kind and person-centred care, with some further work needed on staff meetings and appraisals.
This was a focused inspection on 7 July 2022. One inspector spoke with a person using the home, two relatives and five staff. They reviewed care records, risk assessments, medicine records and management documents.
The home was rated Good overall. Safe, caring and well-led were also rated Good. Inspectors found that medicines were managed safely, staff understood people's needs, and people were treated with kindness, dignity and respect.
The home had improved since the previous inspection, when it was rated Requires Improvement and breached rules about medicines and quality monitoring. At this inspection, the provider was no longer in breach. The inspection did not assess Effective or Responsive.
Medicines managed safely
Inspectors checked four people's medicine records and found them accurate and up to date. Care records also included medicine use and possible side effects.
“We looked at four people's medicines records and found they were accurate and up to date.” from the report
Kind and respectful staff
Staff were patient and used communication suited to each person. Inspectors saw staff help people become calm and relaxed when they were upset or anxious.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Support for independence
People were supported to learn skills, make choices and try new activities. Records showed progress with personal care and other goals.
“People had learned how to have a shower and use the toilet without the need for physical support.” from the report
Care reflected people's identity
The home recorded people's likes, dislikes, cultural needs and religious preferences. People were supported to observe their faith, while staff also respected any decision not to follow it.
“Care records showed people's religious and cultural needs had been identified and there was a clear description of support needed.” from the report
Improved management oversight
The provider used audits and an action plan to monitor care and address shortfalls. The previous breach relating to governance had been resolved.
“The provider completed a range of audits to monitor the quality of care being delivered in the service.” from the report
Staff development records
minorA recent external audit identified a need for more staff one-to-one meetings and staff appraisals. The manager and provider said they were committed to making these improvements.
“One area for improvement was the need to have more staff one to one meetings and conduct staff appraisals.” from the report
- 01How often are staff one-to-one meetings and appraisals now completed?
- 02How will you make sure medicines records remain accurate and up to date?
- 03How will my relative be supported to build independence and work towards their personal goals?
- 04How will my relative's communication method, religious needs and personal preferences be recorded and followed?
This was a focused inspection of Safe, Caring and Well-led only; Effective and Responsive were not assessed. This explanation was written from the published report of 25 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2020
Rated Requires Improvement; inspectors found caring and responsive support, but medicines, dignity and quality checks were not always safe or reliable.
This was the home’s first inspection. Inspectors visited unannounced on 16 December 2019 and 17 January 2020. They spoke with one person, three relatives and four staff, and reviewed care, medicines and management records.
The home had enough staff, followed safe recruitment checks and supported people with food, healthcare, communication, activities and religious needs. Care plans were detailed and personalised. Relatives generally described the home as safe, caring and welcoming.
Inspectors found that prescribed creams and medicine timings were not always recorded properly. They also saw a person being spoken to abruptly, and found that quality checks were not strong enough to identify or fix problems. The home was rated Requires Improvement overall, with Good ratings for Effective and Responsive.
Enough staff
Inspectors found enough staff to meet people’s needs. Relatives also said staffing levels were sufficient, including when people went out into the community.
“There were enough care staff to meet people's needs” from the report
Personalised care
Care plans contained detailed information about people’s needs, preferences and communication methods. Staff showed they knew people’s likes and dislikes.
“The plans were detailed and personalised with lots of information about people's needs and preferences.” from the report
Health and dietary support
People were supported to eat and drink safely and had access to healthcare professionals, including dentists, dietitians and speech and language therapists.
“People had up to date health action plans and daily records showed health care professionals were involved in their care” from the report
Activities and relationships
People took part in activities they enjoyed and were supported to keep in contact with family and friends.
“People were supported to maintain relationships to avoid social isolation and to follow their interests during the day time.” from the report
Medicine records
seriousPrescribed creams were not recorded as given, medicine administration times were missing and one person’s side effects were not recorded in their care records or medicine records. This created a risk that medicines might not be given as prescribed.
“Prescribed creams were not being recorded as given on medicine administration records (MAR) as required by national guidelines.” from the report
Dignity and respect
needs fixingInspectors saw a staff member use abrupt words and body language. A person also said they did not always like the language staff used.
“People's dignity was not always promoted when they behaved in a way which challenged the service.” from the report
Weak quality checks
seriousThe home had not established effective systems to monitor quality and safety. A medicine audit was missing, other audits had not been carried out and there was no quality action plan.
“The service was not set up in a way to promote good quality care through effective quality monitoring.” from the report
Gas safety follow-up
needs fixingThe home had not completed steps required by the gas safety assessment. Inspectors said this meant people were at risk from malfunctioning equipment.
“Steps had not been taken to comply with the gas safety assessment meaning people were at risk of malfunctioning equipment.” from the report
- 01How are prescribed creams and medicine administration times now recorded and checked?
- 02What action has been taken to complete the gas safety assessment and deal with any equipment risks?
- 03How do you make sure staff always speak to people respectfully when behaviour is difficult to manage?
- 04What quality audits are now completed, and how are problems recorded and followed through?
- 05Has the deputy manager post been filled, and how often are staff meetings and supervisions now held?
This was the first inspection of the newly registered care home and covered all five CQC questions, including the care provided and the premises. This explanation was written from the published report of 26 March 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bayis Sheli Limited
2 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- August 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2020Requires improvementSafe: Requires improvementCaring: Requires improvementWell-led: Requires improvement
- February 2019
Registered with the Care Quality Commission on 13 February 2019.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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