Bevancare Ltd provides care and support to people living in their own homes. Not everyone using Bevancare Ltd received regulated activity; the CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do, we also take into account any wider social care provided. Site visits were carried out on 16 and 21 July 2025. At the time of this inspection 55 people were being supported by Bevancare Ltd; 26 were receiving support with personal care. This inspection was triggered by information we held about the service and to see if the service had improved. We looked at 17 quality statements and judged that the service had improved and was no longer in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Good Governance. This assessment was carried out by two inspectors. An expert by experience made calls to people on 18 July 2025. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. During this assessment we spoke with the registered manager, 2 care co-ordinators, an administrator and 6 care staff. There were electronic call monitoring systems to ensure staff attended care visits on time to administer people’s medication, where required; systems were in place to safeguard people from abuse. Risks were identified and assessments were in place to ensure people received safe care; these needed to be more robust so that specific risks relating to individuals were fully captured. Staff were recruited safely. There were quality assurance systems to ensure people received safe care. The registered manager was aware of the areas that needed to be more robust. There were quality monitoring systems to obtain feedback. The service worked in partnership with other professionals to ensure people were kept safe and lived their lives how they wished to. We were told by a professional we contacted that staff went ‘over and above’ to ensure people received good care and support.
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Bevancare Ltd was rated Requires Improvement overall following a focused inspection in May 2023, with a regulatory breach identified under Regulation 17 for failure to maintain accurate medicines administration records. Strengths included person-centred care, robust recruitment, good infection control, and positive staff and management culture, though improvements were needed in MAR accuracy, visit timing monitoring, and governance oversight.
Concerns (5)
criticalMedication management: “Some MARs lacked vital information. For example, people's name, allergy status, and the dates medicines had been given.”
criticalMedication management: “One MAR said 'Diazepam 1 or 2 per day'. However, we saw MARs that had been signed repeatedly 3 times each day for this medicine.”
moderateRecord keeping: “MARs were hand written, rather than printed. However, there were no signatures to show who had transcribed the information.”
moderateMissed or late visits: “They (staff) were sometimes in and out in 5 or 10 minutes when it was supposed to be 30 minutes”
moderateGovernance: “Auditing of MARs was not always thorough or detailed enough.”
Strengths
· Robust recruitment process with pre-employment checks including DBS, references and employment history
· Staff followed correct infection control practices and wore appropriate PPE
· Person-centred care records containing relevant detail about each person's care needs
· Positive staff culture with regular supervisions, spot checks and team meetings
· Effective complaints handling with thorough investigation and appropriate remedial action
Quality-Statement breakdown (10)
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people; Learning lessons when things go wrongGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
Bevancare LTD improved from requires improvement to good across the safe, responsive and well-led domains, with the previous breach of Regulation 17 (Good Governance) now resolved. Risk management, recruitment, medicines, person-centred care planning and leadership were all rated good, with new quality monitoring systems still being embedded.
Concerns (2)
minorStaffing levels: “Some people told us they had experienced difficulties with changes in staff recently, but that managers had listened and improved consistency.”
minorGovernance: “New systems for quality monitoring were still being embedded.”
Strengths
· Risks to individuals and staff were identified and well managed with care records guiding staff appropriately
· Safe systems for staff recruitment with all required pre-employment checks completed
· Safe administration of medicines with regular competency checks and audits
· Person-centred care records covering identified needs and preferences with regular reviews
· End of life records were very person centred and respected people's choices
Quality-Statement breakdown (12)
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infection; Learning lessons when things go wrongGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood