Baldev Skills Resources Limited

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 that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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

Improvement was found at this assessment, and the provider was no longer in breach of this regulation.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider had a mission statement which outlined their aims and objectives for the service. Staff were aware of their roles and responsibilities and the part they played in supporting people to achieve their goals and aspirations. One staff member told us, “Providing assistance to individuals with various needs as to enable and encourage them to live independently.” Another told us, “Providing care and support to elderly or vulnerable individuals while ensuring their independence and wellbeing.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff felt leaders had the appropriate skills and knowledge to lead effectively and they felt comfortable to raise any concerns should they arise. Manager were committed to ensuring all staff delivered high quality care. Staff records showed evidence of training, induction and shadowing as well as regular competency checks and supervision. Most staff told us they had regular supervision and there was evidence of team meetings which included lessons learned. Some concerns were raised by some staff around pay which we passed onto the provider.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were able to speak with the management team if they needed to. This was also encouraged during staff meetings and supervision. There was a whistleblowing policy in place and staff knew how to access it. There were systems in place for people and their families to speak up and for their voices to be heard. However, some people did raise issues around this, and we asked the provider to review their responses to all issues raised.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had policies and procedures in place regarding equality, diversity and inclusion and staff had received training on equality and diversity. We saw evidence that where needed, the provider made adjustments for staff to support them with their personal circumstances.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had structures in place to monitor and improve the quality of care they delivered. Systems such as audits and quality monitoring were used to check the quality and safety of the service and actions noted to be in place to address issues highlighted. However, as the service had a small number of people receiving a service, audits completed were more individual than service level. We discussed this with the provider who informed us they were already in the process of moving towards utilising the reports from the electronic call monitoring system. They told us this would provide greater service level oversight going forward. Care plans overall were detailed but some areas required more detail and information to guide staff. For example, information around capacity and end of life planning was limited and required improvement to ensure staff had sufficient information to guide them to support people effectively. Overall, the registered manager was aware of their responsibilities to notify partners but was not fully aware of the full range of notifications that needed to be submitted to CQC. The registered manager agreed to rectify this immediately. The provider had a business continuity plan which detailed how they would be prepared for emergencies.

At the last assessment the provider was found to be in breach of the legal regulation relating to good governance. Improvements were found at this assessment, and the provider was no longer in breach of the regulation related to good governance. However, some areas still need further work which the provider agreed to action.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The senior team had a strong commitment to improving the service and were open to suggestions for improvement, recognising the importance of joint working with partner agencies. There was evidence of collaboration and partnership working with partner agencies and other stakeholders. The registered manager regularly attended provider forums and meetings. One professional commented, “I’ve observed a strong commitment to person-centred care, and their communication with both clients and professionals has been excellent.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. There were systems in place to gather feedback from people, their families and staff in order to improve the service. Team meetings included discussions about learning and improvement. Complaints, compliments, accidents and incidents were reviewed and analysed. The provider was in the process of utilising the reporting system on the new electronic recording system to provide wider service level oversight. Staff said they felt they had adequate induction and training and that they would be provided with further training if they requested it. One staff member told us, “I appreciate the growth opportunity in this role and hope to advance my development through continuous training.”