Besi Care Ltd

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

Well-led – this means we looked for evidence service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant management and leadership of the service was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance of the service. 

This service scored 43 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The management team provided evidence of staff meetings but did not provide evidence of their vision or strategic planning for the development of the service. The provider did not have organisational policies, processes or systems in place.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. The provider submitted limited evidence for this quality statement. Discussions with the registered manager and nominated individual confirmed the provide did not have any organisational policies, processes or systems in place. The management team confirmed they recognised this was a failure and they were developing an action plan to implement corrective action.

The provider fostered a positive culture where people could speak up and their voice would be heard. However, the provider did not have the appropriate organisational policies, processes or systems in place for this to be fully supported. Members of staff told us they were listened to by the management team. One staff member said, “I’m encouraged to suggest new ideas about how care could be delivered. We share ideas during team meetings, supervision, or directly with the management team.”

The provider valued diversity in their workforce. However, the provider did not have the appropriate organisational policies, processes or systems in place to ensure members of staff had access to information and guidance about equality and diversity. Members of staff received supervision and support from the management team. The wider staff team were encouraged to provide feedback about the service but the management team had not reviewed or analysed the responses.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. The provider did not have any governance systems, audits, quality monitoring processes or organisational policies in place. Discussions with the provider and the management team confirmed key documents were not in place and improvement was required.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. The provider submitted limited evidence to support this quality statement. Organisational policies, processes or systems were not in place to support collaborative, partnership working across local communities and with health and care professionals.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research. We received limited assurance the management team understood continuous service improvement. The provider informed us a learning framework was in place but there was limited evidence to support this and policies, processes or systems were not in place to support improvement through learning. When we met with the provider the acknowledged and understood the areas where improvement was required.