Beige Healthcare Services

​The provider was in breach of the legal regulation relating to effective governance. Improvements were required to ensure systems and processes consistently supported safe and effective care. While staff understood the signs of abuse and would report concerns to the registered manager, there was a lack of understanding regarding when and how to make referrals to the local authority safeguarding team. Some risk assessments were incomplete, lacked sufficient detail, or had not been reviewed appropriately. Recruitment processes were not robust, as records showed gaps in employment histories and missing references.

Although staff and the registered manager demonstrated good knowledge of people’s needs, care records did not consistently reflect this. Care plans lacked sufficient information about people’s health conditions, communication needs, monitoring of equipment and professional involvement. There was also conflicting information within 1 care plan and gaps in recording actions taken when people reported pain and discomfort. While daily records showed staff generally followed care plans and people’s preferences, opportunities to evidence choice and actions taken in response to concerns were sometimes missed.

Governance arrangements were not fully effective. Essential documentation such as safeguarding logs, policies, rotas, care plans, risk assessments and a business continuity plan were in place. However, there was limited evidence of formal quality assurance processes, including audits, supervision records, competency assessments, staff meetings, training oversight and formal feedback systems. The registered manager acknowledged these shortfalls and had developed an action plan with timescales to strengthen oversight and improve governance.

However, people using the service consistently spoke positively about the care provided. They described staff as kind, caring, respectful and knowledgeable, and said they felt involved in decisions about their care. Feedback highlighted staff promoted people’s independence, respected their choices and preferences, maintained dignity, and were flexible in supporting people to live their lives as they wished. One relative also praised the registered manager’s communication and coordination of healthcare appointments and professional involvement.

There was evidence people received support to access healthcare services when required. The registered manager worked proactively with GPs, pharmacies, district nurses, opticians and other professionals to help meet people’s health needs. Records demonstrated action had been taken following incidents, including liaising with family members and healthcare professionals and taking steps to improve medication management. Staff were able to describe how they would respond to emergencies and incidents, understood infection prevention and control practices, and could explain safe medication administration and the safe use of equipment.

Staff spoke positively about the support they received from the registered manager and described a culture of open communication. They reported receiving induction training, shadowing opportunities, regular contact with management and updates regarding people’s changing needs. People and relatives generally felt staffing arrangements met their needs, with care visits taking place at appropriate times and for the planned duration.

Overall, people received caring and person-centred support from staff who knew them well and worked collaboratively with families and healthcare professionals. However, improvements were needed in safeguarding knowledge, risk management, recruitment practices, record keeping and governance systems to ensure safe, consistent and sustainable service delivery.

We have asked the provider for an action plan in response to the concerns found at this assessment.