Headquarters BC Care Ltd

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• 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 that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance bout safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the way people’s medicines were managed and in relation to safe staffing.

This service scored 47 (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 always have a proactive and positive culture of safety based on openness and honesty. Lessons were not learnt to continually identify and embed good practice. At the time of the assessment, no accidents, incidents, or falls had been reported despite 1 safeguarding incident occurring. Lessons learnt were not evidenced from this occurrence and we therefore could not be assured the provider had addressed this appropriately or taken action to learn from the event. Staff told us they knew they would need to report these to the registered manager if they occurred. However, staff feedback and practice were not being regularly reviewed, and only 1 spot check had been completed in the past year.

This lack of structured review and reflection meant opportunities to learn from practice, identify patterns, and drive improvement were being missed. Without effective systems to capture and analyse learning, there was an increased risk issues could be repeated and that improvements in safety and quality would not be sustained.
 

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.
Pre-assessments were completed in a detailed and robust manner. They captured the key information needed to determine whether the service could safely meet a person’s needs before starting a care package. The pre-assessment policy was in place and being followed, and information gathered informed people’s initial care plans.
While some people using the service were also supported by other professionals, such as district nurses, falls teams, or day services, there was limited evidence of how information was shared or how the service worked collaboratively with these agencies. Further development in this area would help strengthen care coordination.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

There was no overall systemin place to capture safeguarding issues for all service users. While no safeguarding concerns had been reported internally, the absence of a formal process meant there was no way to record or monitor any issues should they arise. This reflected a wider lack of systems to monitor the quality of the service, including areas such as medication management.
There was also no overview for CQC notifications, or the responses provided, which made it harder to maintain a clear picture of key events or actions taken.

All staff had completed safeguarding training and knew the procedure for reporting concerns. However, the nominated individual explained that while they were responsible for managing safeguarding, they would refer concerns to the registered manager for guidance before taking action. This could delay timely responses to safeguarding issues.

During the assessment, we observed an incident in which a staff member failed to follow the provider’s policy. Appropriate processes, insurance, and risk assessments were not in place, and staff did not recognise the risks or understand the potential implications of their actions. This placed people at risk of harm and demonstrated weaknesses in safeguarding arrangements.
 

The provider did not always work well with people to understand and manage risks.
Risk assessments were in place for people and were generally reviewed. However, there were significant gaps that required attention. High-risk medications did not have associated risk assessments, meaning staff did not have clear guidance on the potential risks or how to respond to issues such as missed doses or potential side effects.
We also identified contradictions within some risk assessments. In 1 risk assessment it stated family members would cease administering medication, yet staff reported the family remained involved, as did they. This created the potential for confusion and could compromise the safe delivery of care. There was no clear schedule for the oversight and management of risks.
Environmental risk assessments had not been completed for all people, although pre-assessments did evaluate homes and no immediate risks were identified.
While staff were aware of the incident reporting procedure, the gaps in risk assessments placed people at potential risk of harm and demonstrated weaknesses in the oversight and management of risk within the service.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.
During the assessment, we saw that 1 person had a formal environmental risk assessment in place, but the other 3 people whose records we reviewed did not. Pre-assessments did include checks of the environments, where no immediate risks were identified. Formal risk assessments had not been completed for all service users and therefore ongoing risk was not being recorded as being assessed.
However, feedback from people and relatives confirmed people were safe living in their own homes and they had no concerns over staffs' awareness of environmental safety.
 

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.
During the assessment, we saw policies were in place for recruitment, training, supervision, and induction; however, these were not consistently followed in practice. In the sample of staff files reviewed, some did not have signed contracts, completed references were missing from files, and some did not have records of qualifications or prior training. This meant required recruitment checks, as outlined in the provider’s own policy, had not been fully completed, placing people at potential risk.
Induction processes were also not sufficient. Induction materials were generic and did not reflect the nature of the service. Some staff had not completed their induction or had not had it signed off within the expected timeframe.
Supervision and competency monitoring was limited. Only 1 spot check had been completed across the year on 1 staff member, and supervision records were brief, showing little reflection or clear next steps. There was no matrix in place to track when supervisions or spot checks were due.
Training records indicated that while staff had now completed core training, some had started work without completing it for several months. There was no system in place to track completed training, refreshers due, or gaps.
Overall, the lack of oversight and monitoring of staff processes increased the risk that people could receive unsafe or inconsistent care.
 

The provider did not always assess or manage the risk of infection.
During the assessment, staff confirmed they had access to personal protective equipment (PPE) and understood when it should be used. Only 1 spot check had been completed on staff this year, which was not in line with the providers policy. The spot check did look at uniform and PPE compliance. No concerns were raised by people using the service or their relatives.
The Infection Prevention and Control (IPC) policy was in place but had not been fully implemented. For example, the policy referred to appointing a champion responsible for monitoring staff practice and hand hygiene, but this had not been put in place, and monitoring checks had not been carried out.
The policy also outlined staff training should be appropriate to their role, recorded on the training matrix, and supplemented with ongoing observation, supervision, audits, and practical observation. None of these monitoring processes were in place or being consistently followed, which meant we could not be assured IPC practices were fully embedded across the service.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.
During the assessment, we found systems and processes for managing medicines were not in place, which meant medicines were not being managed safely. There was no medication administration records (MARs) or topical medication administration records (TMARs) for staff to record when medicines or creams were given. Medication care plans were not always in place where required, to guide staff on what had been prescribed or how to support people safely with their medicines.
No risk assessments had been completed to identify high-risk medicines or to provide guidance for staff on what to monitor. For medicines prescribed to be taken as needed (PRN), or with variable doses, there were no clear protocols in place to direct when these should be administered, how much, or how staff should record their effectiveness.
Because the required documentation was not in place, medication audits could not be completed. This meant the service could not demonstrate people were receiving their medicines as prescribed, or that any errors or omissions would be identified and addressed. The lack of safe medicines management placed people at significant risk of harm.