Besi Care Ltd

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

The provider promoted a positive learning culture, with accidents and incidents recorded, reviewed and audited to identify themes, embed learning and reduce the risk of recurrence. Safe systems supported continuity of care and the appropriate sharing of information when people’s care arrangements changed or they moved between services. Safeguarding processes were effective, members of staff understood how to recognise and report concerns, and people’s rights were supported in line with the Mental Capacity Act 2005. Person-centred care plans identified people’s needs, preferences and individual risks, while daily records and environmental risk assessments helped members of staff provide safe, consistent care in people’s homes. Safe recruitment checks, relevant training, supervision, spot checks and management oversight helped ensure there were sufficient suitably skilled and supported members of staff. Infection risks were managed through policies, audits, training and access to personal protective equipment. Appropriate policies, monitoring arrangements and procedures were in place to ensure medicines could be managed safely when needed.

People’s health, care, wellbeing and communication needs were assessed with them, recorded in personalised care plans and regularly reviewed to ensure support remained current, consistent and effective. Care and treatment were planned with people and delivered in line with legislation, recognised good practice and relevant standards, with nutritional and hydration needs appropriately assessed and monitored. Members of staff worked effectively as a team and with other services, using regular meetings and appropriate information sharing to coordinate care and provide consistent support. People were supported to maintain their health, wellbeing, independence, choice and control, including access to healthcare professionals and help to make healthier choices when needed. The provider monitored care, treatment and outcomes through regular reviews, including formal care plan reviews every 3 months, enabling changes in people’s needs to be identified and addressed. People’s consent was sought and recorded, and members of staff understood the Mental Capacity Act 2005 and the importance of supporting people to make their own decisions wherever possible.

People were treated with kindness, empathy and compassion, and their privacy and dignity were respected. Members of staff understood how dignity and respect related to people’s individual worth, autonomy, preferences, decisions and independence. Care and support were tailored to each person’s needs, strengths, abilities, aspirations, culture, background and protected characteristics, with personalised care plans guiding members of staff. People were supported to make choices, maintain relationships with those important to them and participate in their communities, promoting independence, choice and control. Members of staff listened to people’s needs, views and wishes and responded promptly to immediate needs to minimise discomfort, concern or distress. The provider promoted workforce wellbeing through accessible management support, supervision, appraisal, training and opportunities for members of staff to contribute ideas, enabling them to deliver person-centred care.

The provider had a clear vision, values and culture which promoted safe, high-quality, person-centred care, dignity, equality, inclusion, choice and independence. Leaders had the skills, knowledge and experience to manage the service effectively, and regular management meetings supported oversight and continued service development. Policies, staff meetings and approachable leadership enabled people and members of staff to speak up, share their views and have concerns heard. The provider promoted workforce equality, diversity and inclusion through regular supervision, individual support and a fair and supportive working environment.

People received person-centred care which reflected their individual needs, preferences and choices, and they were involved in developing and reviewing their care plans. Care was coordinated with relevant health and care professionals to promote continuity and respond to people’s health and wellbeing needs. The provider supplied accurate, up-to-date information in accessible formats, including a service guide tailored to people’s communication needs and preferences. People could share feedback, ideas and complaints through clear processes, and the provider used feedback from people and members of staff to support learning and improvement. People could access timely care and advice when needed, supported by an on-call system available during evenings and weekends, and no barriers to care were identified. Members of staff understood people’s individual circumstances, communication needs, preferences and routines, helping to promote equitable experiences, community inclusion and meaningful activity. Processes supported people to consider and express their wishes for future and end-of-life care at an appropriate time.

Governance arrangements had significantly improved, with clear accountability, comprehensive policies, audits and quality assurance processes used to monitor risk, performance and the quality and safety of care. The provider worked proactively with commissioners, healthcare professionals and other partners to coordinate care, share information and meet people’s needs effectively. Learning from the previous inspection had led to improvements in policies, systems and processes, establishing a sound foundation for continuous learning and service improvement.