Beverley Martins Limited was rated Requires Improvement overall following a November 2017 inspection, with two regulatory breaches found: Regulation 12 (safe care and treatment) for inadequate risk assessments, and Regulation 17 (good governance) for incomplete care records. The service was Good for caring, with staff demonstrating compassion and respect, but failed to maintain sufficiently detailed, personalised care plans and lacked effective internal monitoring to identify these shortfalls.
Concerns (6)
criticalCare planning: “risk assessments and support plans contained some information for staff, but did not contain a sufficient level of detail about how care workers were expected to mitigate known risks.”
criticalRecord keeping: “The provider did not always maintain an accurate and complete record in respect of each service user. Regulation 17(1)(2)(c).”
moderateGovernance: “the organisation's internal monitoring did not include a check of people's care records and therefore, the issues we found in relation to people's care records had not been identified.”
moderatePerson-centred care: “most care records contained either very limited or no information about people's life history or preferences in relation to how they wanted their care to be delivered.”
moderateCare planning: “we did not find evidence of specific risk assessments relating to the risk of people falling in any care records we viewed.”
minorCare planning: “care records did not always include exact details of what assistance people needed in relation to their nutrition.”
Strengths
· Safeguarding procedures were in place and staff demonstrated good understanding of how to recognise and report abuse.
· Medicines were administered safely; MAR charts reviewed monthly by senior staff with discrepancies followed up.
· Recruitment processes were thorough, with employment histories, references, ID and DBS checks completed before staff started.
· Sufficient staffing levels in place; visit timings could be extended if required.
· Staff received induction, mandatory training, regular supervision every two months, and annual appraisals.
Quality-Statement breakdown (14)
safe: Risk assessment and care planningRequires improvement
safe: SafeguardingGood
safe: Medicines managementGood
safe: Staffing and recruitmentGood
effective: Nutrition and care record detailRequires improvement
Beverley Martins Limited improved from Requires Improvement to Good across all rated key questions, having addressed previous breaches of regulations 9, 12, 14 and 17. One recommendation was made regarding the recruitment policy requiring only a five-year work history, which did not fully meet current requirements.
Concerns (1)
minorRecord keeping: “we identified the policy was to request only a five-year work history when recruiting new staff. We recommend the provider review their recruitment procedure to ensure it fully meets current requirements.”
Strengths
· Significant improvements in risk assessment and mitigation since previous inspection, with clear guidance for staff on supporting people safely.
· Medicines managed safely by trained staff with regular audits by senior staff and external pharmacy consultancy.
· People supported by familiar, consistent carers who understood their needs and treated them with kindness and dignity.
· Care plans improved with detailed personalised information including cultural, religious, nutritional and medical needs.
· Provider no longer in breach of regulations 9, 12, 14 or 17 following improvements made since previous inspection.
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
Beverley Martins Limited received a 'Requires Improvement' rating across all five key questions at this January 2019 inspection, with warning notices served for breaches of Regulations 9 and 12 relating to person-centred care and safe care and treatment. Persistent failures from the previous 2017 inspection remained unresolved, including inadequate risk assessments, inaccurate medicines records, poor care plan personalisation, inconsistent MCA compliance, and governance systems insufficient to identify or address these issues.
Concerns (9)
criticalCare planning: “risk assessments were either not in place or contained unclear or inconsistent information for care workers particularly in relation to people's moving and handling needs”
criticalMedication management: “medicine records were not always accurately completed... one person's MAR for October contained three gaps, but there was no information recorded to indicate why”
criticalConsent / capacity: “records were not always signed by the person using the service or their legally authorised representative... a mental capacity assessment that did not conclude whether or not the person had capacity”
criticalGovernance: “provider had auditing systems in place, but these were still not consistent... MAR charts for three people... were not available. Daily notes that were available were for September”
criticalPerson-centred care: “care records contained very limited details about people's individual needs and preferences... one person's care record did not have a list of tasks included at all”
moderateRecord keeping: “care records contained very limited personalised information about their care needs or their backgrounds”
moderateSupervision / appraisal: “most care workers were receiving either one or two supervision sessions in 2018... some care workers had not received an appraisal in 2018”
moderateCare planning: “care records did not always contain information about people's likes and dislikes in relation to food... no information about the type of food the care worker was required to prepare”
minorCommunication with families: “They don't tell me they are sending someone different, it's irritating”
Strengths
· Appropriate safeguarding processes in place with care staff demonstrating good understanding of their responsibilities
· Safer recruitment practices in place with appropriate pre-employment checks including DBS checks
· Sufficient staffing levels with appropriate travel time allocated between calls
· Induction programme covering Care Certificate standards with ongoing refresher training
· Complaints investigated and responded to in a timely manner
Quality-Statement breakdown (15)
safe: Risk assessment and care planningRequires improvement
safe: Medicines managementRequires improvement
safe: SafeguardingGood
safe: Staffing levels and recruitmentGood
effective: Nutritional and hydration needsRequires improvement
effective: Consent and Mental Capacity ActRequires improvement
effective: Staff training and inductionGood
effective: Supervision, spot checks and appraisalRequires improvement
Beverley Martins Limited received a Good rating across all five key questions at its February 2016 inspection, with 132 people receiving domiciliary care. The service demonstrated strong safeguarding practices, person-centred care, effective staff training and supervision, and robust quality assurance systems with no regulatory breaches identified.
Strengths
· Staff were trained in safeguarding, could recognise signs of abuse, and knew how to report concerns promptly to the local authority.
· Robust recruitment practices including DBS checks, references, and identity verification protected people from unsuitable staff.
· Medicines were managed safely; MAR charts were audited and staff understood correct procedures including for refusals.
· An electronic monitoring system detected and resolved late or missed visits promptly.
· Staff received regular supervision, annual appraisals, and ongoing training including dementia awareness, MCA and DoLS.
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Continuous learning and improving careGood
well-led: Working in partnership with othersGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
caring: Continuity of care workersRequires improvement
caring: Privacy and dignityRequires improvement
caring: Person-centred care recordsRequires improvement
responsive: Care planning and personalisationRequires improvement
responsive: Complaints handlingGood
well-led: Quality assurance and governanceRequires improvement
well-led: CQC notifications and regulatory complianceGood