Archived: Betheli Limited

Below is a summary of what we found. At the time of our inspection the provider was not supporting any people who use the service. Therefore, the summary is based on inspectors speaking to the registered manager and looking at the records in place.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Safeguarding policies and procedures we reviewed were not robust. The registered manager we spoke with did not fully understand how to safeguard the people they supported. The agency did not have any care packages therefore we could not check if people felt safe and trusted the staff. We could not check staff's knowledge as they have not started work yet.

Systems were in not place to make sure the manager and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This would not reduce the risks to people and help the service to continually improve.

We could not check if people who would use the service had a choice and control of their lives and how their support would be planned. The manager did not fully understand the importance of making sure the person who would use the service had the right to choose the way support and care is provided. The manager did not fully understand the process of making sure decisions are taken in an appropriate way when the person who would use the service did not have capacity. The manager could not fully explain how they would test individual's mental capacity.

Appropriate training arrangements were not in place. The manager did not have systems in place to plan and monitor staff's training and induction. We did not see any training policy, schedule or matrix for training sessions. We could not check if staff had the right skills and experience to ensure people's needs would be always met.

Is the service effective?

We could not check if people's health and care needs would be assessed with them as the agency did not have any care packages. The manager did not have comprehensive documents to assist them to carry out initial assessments and develop a care plan and individual risk assessments further.

We could not check if the agency were respecting people's wishes and preferences. The agency did not have appropriate arrangements to seek consent or involve advocacy services for people who would use the service.

Is the service caring?

We were not able to judge fully if the provider met the requirements as there were no people who use the service to talk to. However, we looked at the records the registered manager put in place. We saw a feedback form had been devised that would help seek people's views. There was no regular contact to be made according to the manager and no other means of seeking people's views about the services they would receive.

We could not speak with people who would use the service about their staff and the quality of the services provided. We could not speak with staff to tell us how they cared for the people who would use the service.

Is the service responsive?

We were not able to check if people who would use the service knew how to make a complaint or raise an issue with staff and manager. We looked at the complaints policy and how issues raised would be responded to. The complaints policy was not reviewed recently.

We could not check how the agency worked with other professionals as the agency did not support any people at this time. The manager told us they would work with doctors or district nurses if medical assistance was needed.

Is the service well-led?

The provider did not have a quality assurance system in place. Records we looked at showed the service did not have appropriate processes to identify problems and procedures to act on any concerns identified.

We could not speak with staff about their role and responsibilities. Records and arrangements we reviewed were not appropriate and supportive to the staff who would work at the agency. This would not make sure people who would use the service received care and support of good quality.

Below is a summary of what we found. At the time of our inspection the provider was not supporting any people who use the service and there were no staff working at the agency. Therefore, the inspection is based on inspectors speaking to the registered manager, one care worker who was employed by the agency but not working at the moment and looking at the records in place.

Before we commenced the inspection, we asked the provider if they considered themselves dormant. When a provider is registered but nobody is using either a location or a regulated activity (RA), we refer to it as a dormant service. We had to clarify the meaning of the term to the provider. The provider confirmed they understood and did not consider the business to be dormant. The provider confirmed they had voluntarily chosen not to accept any packages until they have reached compliance with regulations.

We asked the provider about their role and responsibilities for ensuring they were operating a safe and appropriate service. They told us they had policies and procedures in place. They also said they had a procedure to enable them to recruit and train suitable staff, supervise them and make sure they knew their responsibilities. The provider told us staff had responsibility for making sure they communicated well with people, carried out risk assessments, taking care of people's needs and obtaining consent for care and treatment. When people start using the service, the provider would ensure they were safe, happy, and receive good care and equipment to support them. The provider had a legal responsibility for their service. They informed us they had looked at CQC requirements and revised their policies and procedures in April 2014 to ensure people and staff 'were taken into account' when receiving and delivering support. We asked the provider with regard to notifying us about the events or changes affecting the service. They were able to describe events which would require notification to CQC.

We asked the agency about their statement of purpose, aims and objectives, vision and values. The provider explained the people they would support were at the centre of the service. They would ensure their staff were trained and experienced to be able to support them. The provider would empower people to have a voice and raise any concerns with them. We asked to see the agency's statement of purpose. The registered manager informed us they had not reviewed the statement of purpose.

We found that the service did not fully understand how to keep people in their care safe and there were no appropriate policies and procedures available to help them.

The service did not have a robust recruitment process to ensure staff were suitable and safe to work with the people who used the service.

We found that staff were not supported to enable them to offer the best care.

We found that the service did not have ways of looking at the care they offered so that they could make sure they maintained and improved it. They did not have a way of listening to the views of the people used the service.

We saw that the service did not have ways of checking health and safety which would keep people who used the service and staff as safe as possible.