Besi Care Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

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.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The provider had effective systems and processes in place to record, analyse and review accidents and incidents. Monthly audits were completed to identify any themes, trends or areas where improvements could be made. This supported effective oversight and demonstrated a positive approach to learning from incidents and reducing the risk of recurrence.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Clear and effective processes were in place to support continuity of care. Relevant information was shared appropriately to help ensure people received safe, consistent care and support when moving between services or during changes in their care arrangements.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way for this to be achieved. Members of staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns with the local safeguarding adults team quickly and appropriately. Effective safeguarding systems, processes and policies were in place to protect people from abuse and avoidable harm. There were clear arrangements for identifying, reporting and escalating safeguarding concerns to the local authority and other relevant agencies when required. The provider had a Mental Capacity Act 2005 (MCA) policy in place, and records demonstrated people’s mental capacity was appropriately considered, reviewed and documented. The provider followed the principles of the Mental Capacity Act 2005 (MCA) to review people’s capacity and understanding around receiving care and support. The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires people, as far as possible, to make their own decisions and receive help to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. Members of staff demonstrated a good understanding of safeguarding responsibilities and knew how to recognise, report and escalate concerns. Members of staff had access to safeguarding guidance and understood the actions they should take if they suspected abuse or unsafe practice, including protecting the person, reporting concerns to the manager and involving relevant external agencies where appropriate. This demonstrated members of staff understood their responsibility to act promptly to help keep people safe. A member of staff told us, “I will tell my manager if I see a colleague providing dangerous care.”

The provider worked with people to understand and manage risks by thinking holistically. Care was provided to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. People’s care plans were person-centred, appropriately detailed and reflected their individual care and support needs. Care needs were clearly identified, including people’s preferred routines, and associated risks had been assessed with appropriate measures in place to reduce identified risks. Members of staff maintained daily records of the care and support provided, supporting continuity and consistency of care. Members of staff told us they could access people’s care plans from records held in their homes, which helped ensure they had the information needed to provide safe and appropriate support.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Risks associated with providing care and support in people’s own homes were appropriately assessed and managed. The provider had a risk management policy and processes in place to support staff to identify and reduce potential risks to people. The provider monitored and reviewed call logs and daily care records to maintain oversight of care delivery and ensure care calls were completed effectively and on time, in line with people’s assessed needs and expectations.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care which met people’s individual needs. Members of staff were recruited safely and had the appropriate training and support to provide safe and effective care. Pre-employment checks were completed, and staff employment records were regularly audited and reviewed by the management team which provided assurance safe recruitment procedures had been followed. Members of staff completed training relevant to their roles and the needs of people they supported. Training was monitored through a training matrix, enabling the management team to maintain oversight and identify when training required updating. The management team carried out spot checks to monitor staff practice and the quality of care and support provided. This helped ensure members of staff continued to work safely and effectively, and appropriate standards of care were maintained. A member of staff told us, “I do all the mandatory training, and also specific training to suit people’s needs, for example, dementia.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The provider had infection prevention and control (IPC) policies and processes in place to support safe care practices. The management team completed IPC audits to maintain oversight and monitor standards. Members of staff confirmed they had access to appropriate personal protective equipment (PPE) and had received relevant training.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. The provider had effective systems, policies and processes in place to support the safe management and administration of medicines. Arrangements were in place to monitor and review medicines management and maintain appropriate oversight of practice. At the time of the assessment, no one using the service required support with their medicines. However, the provider had established comprehensive procedures to ensure medicines could be managed safely and effectively should people require this support in the future.