Betna Agencies Ltd improved from Inadequate to Good overall, with previous breaches of regulations 12, 17 and 19 resolved and registration conditions removed. Well-led remained Requires Improvement due to incomplete medicines and governance records, audit gaps and limited oversight of staff COVID-19 testing.
Concerns (5)
moderate
Medication management
: “audits of MAR charts were not always effective at identifying where records required improvements. We found examples of where staff had not always completed MAR chart records in line with good practice.”
moderateRecord keeping: “The provider's accident book did not record details for a relevant incident and not all records were disposed of in line with the provider's policies.”
moderateGovernance: “Records for medicines administration and governance and oversight arrangements were not always fully complete. The provider's policy framework was up to date and comprehensive, however not always fully embedded and followed.”
minorStaff competency: “the provider was also required to complete medicines competency checks for staff... However, records to support this were not robust.”
minorLeadership: “Staff did not consistently report to the registered managers the results of their COVID-19 weekly tests... This meant the registered managers did not have oversight of the testing staff were expected to complete.”
Strengths
· Recruitment processes improved with all required checks now completed, including DBS, references and employment gap checks
· Care plans and risk assessments up to date and accurate, with guidance from other professionals
· Staff trained and knowledgeable in safeguarding, infection prevention and control including COVID-19
· People and relatives reported caring, friendly staff who promoted privacy, dignity and independence
· Personalised care reflecting life histories; communication needs assessed with visual aids where helpful
Quality-Statement breakdown (22)
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and process to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choicesGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; supporting access to healthcareGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisionsGood
responsive: Planning personalised care to ensure choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationshipsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Duty of candour and continuous learning and improving careRequires improvement
well-led: Promoting a positive, person-centred culture; engaging people and staffRequires improvement
well-led: Working in partnership with othersRequires improvement