Baldev Skills Resources Limited

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 that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

The service was previously in breach of the legal regulation in relation to fit and proper persons employed. Improvement was found at this assessment, and the provider was no longer in breach of this regulation.

This service scored 69 (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. Where people’s needs had increased, we saw evidence of partnership working to ensure people received the level of support they needed, and people were kept safe. We found the management team were open and transparent and wanted to drive improvement at the service. One professional commented, “I was impressed by their openness and genuine desire to improve their service and get it right for the sake of their clients and staff wellbeing.”

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. Assessments of people’s need and associated risks were completed during the initial assessment of care to ensure safe and effective support. Information in care records provided sufficient guidance to staff to allow them to support people safely and allow effective information sharing between other parties. We asked the provider to review some areas of care documentation including during assessment to reflect in more detail the support people required. The provider agreed to action this immediately. When people’s needs had changed, timely referrals were made to ensure the correct care and support was in place, this included requesting additional support if required.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. However, the provider did not always share concerns quickly and appropriately and care records did not always reflect the detail of how the service was working within the principles of the mental capacity act. Systems were in place to provide oversight of accidents and incidents which were reviewed to identify themes and trends. Most incidents were appropriately reported as required to external parties. However, the provider was unaware of the full range of incidents that needed to be reported, resulting in some incidents not being reported to CQC. The provider agreed to revise their systems to address this and ensure all parties received necessary information in a timely way. As a small service, audit systems in place tended to provide more individual than service level oversight. We asked the provider to review their current audit systems to provide increased service level oversight to align with any future growth. The provider was already in the process of exploring options within their electronic monitoring system to address this. Staff had completed safeguarding training and the providers safeguarding policy guided staff about different types of abuse, and how to raise a concern to ensure people were protected. One staff member told us, “First document it and report my suspicions, offer support to the victim involved so they won’t feel neglected and follow up to make sure the concern raised is sufficiently and rightly addressed.” Another staff member told us, “I would report it straight away to my manager or safeguarding lead and follow safeguarding procedures.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people's health, safety and well-being were well managed. There were processes in place to identify risk, which then led to detailed plans being put in place for staff to follow to reduce or remove risk. People's risk assessments were reviewed regularly or as required, such as in response to their changing needs or after a significant event. Staff had completed a range of training including positive behaviour support training to assist staff in managing risk. One staff member told us, “I learned about communication strategies, behavioural support techniques and I apply this knowledge by adapting my communication to meet the needs of the individual.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Prior to people receiving support at the service, an assessment of the environment was completed with regular reviews by the provider to ensure both people and staff were safe. Staff were aware of risks associated with the environment and knew where to find the information on environmental risks to guide them.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. We received mixed feedback from people and relatives regarding calls and the continuity of staff. One relative told us, “Can’t guarantee what time they are coming.” Another relative told us, “Sometimes only one turns up and they have to struggle themselves.” We reviewed the electronic records of support provided and where support was not provided as planned, call monitoring information identified reasons for changes taking place. We discussed with the provider communication with people and families around call times and the option available for them to remotely access call information from the electronic call monitoring system. We also discussed revising audits of call monitoring to allow easier oversight to ensure that arrangements were in place to ensure people were being supported safely as identified by their care plan. The provider was in the process of replacing manual call monitoring reports and utilising the reporting system on their electronic system to provide call monitoring analysis. Recruitment procedures were in place, so people were cared for by suitably qualified staff who had been assessed as safe to work with people. However, it was noted that employment history for some candidates did not always include all information back to leaving school. Where references from most recent employers were not provided, we recommended keeping a record of the trail of requests on individual files for easier reference. People were supported by staff who were trained and competent to deliver safe care. Staff working with adults with a learning disability or autistic people had completed training in learning disability and autism which was in line with the Oliver McGowan Code of Practice. One staff told us, “I have had training in supporting individuals with learning disabilities, dementia awareness and autism. This has fully enhanced my knowledge to understand different communication methods and behavioural needs which helped me to apply a person-centred approach and give effective support.”

At the last assessment the provider was found to be in breach of the legal regulation relating to fit and proper persons employed. Improvements were found at this assessment, and the provider was no longer in breach of the regulation related to fit and proper persons employed. However, some areas such as employment history still required further review. The provider agreed to action immediately.

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. Staff received training on infection, prevention and control (IPC). There were no concerns raised by staff about the availability of personal protective equipment (PPE).

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Staff were trained in medicines administration, and their competency had been assessed. People were supported by staff who followed systems and processes to administer, record and store medicines safely. People and their relatives were mainly positive regarding support with medicines. One relative told us, “They make sure there is a MAR (Medication Administration Record). Carers are insistent and professional like that. Never have any problems with medications.” One relative was unsure due to issues they raised with call times whether their relative was receiving their medicines as prescribed. Records reviewed showed that medicines had been given. We asked the provider to monitor this. The provider had a medicines policy, and this reflected the principles of STOMP (stopping over-medication of people with a learning disability, autism or both). People were supported with their medicines in line with the policy.