BCP Supported Living Service improved from Requires Improvement to Good across Safe, Effective and Well-led domains, having resolved a previous breach of Regulation 17 relating to governance. The service demonstrated sustained improvements in oversight, staff training, medicines management, safeguarding and person-centred care delivery.
Strengths
· Significant and sustained improvement in staff training with wide range of subjects and competency assessments
· Robust governance and multi-layered oversight introduced, resolving previous breach of Regulation 17
· Detailed, person-centred risk assessments that did not restrict people from living full lives
· Medicines managed safely with correctly completed MAR records and staff competency checks
· Strong safeguarding culture with clear reporting channels and monthly review of concerns
Quality-Statement breakdown (14)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
effective: Staff support: induction, training, skills, and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance, and the lawGood
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
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; Continuous learning and improving careGood
well-led: Engaging and involving people using the service, the public and staff; 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
BCP Supported Living Service was rated Requires Improvement overall, with a Regulation 17 breach for ineffective governance, audit and feedback systems, plus shortfalls in infection control and mandatory training. Caring and responsive domains were Good, with personalised support, kind staff and strong complaints handling.
Concerns (7)
criticalGovernance: “The provider had failed to ensure governance systems were established and operating effectively to ensure risks were managed and learning shared”
moderateIncident learning: “there was no process for analysis and review to enable the service to identify trends, learn lessons from events or prevent reoccurrence”
moderateInfection control: “not all staff had received training in infection control, half of the staff team had not received training and only eight staff out of 68 had received training”
moderateStaff training: “36 staff out of 68 had not completed mandatory epilepsy training and a further 14 staff needed a refresher”
moderateLeadership: “Oversight from a provider level had not identified the shortfalls within the service. The provider told us they did not have a formal audit and measurable system”
minorCommunication with families: “The service had not actively sought formal feedback for the service since 2019.”
minorRecord keeping: “the passports were not always up to date with the correct contact details”
Strengths
· Staff knew people well and demonstrated kind, caring interactions; relatives praised staff highly
· Robust recruitment process including interviews, shadow shifts, competency checks and DBS checks
· Safe medicines management with adherence to STOMP principles
· Personalised, detailed support plans including hospital passports and epilepsy emergency flow charts
· Cultural and spiritual needs respected, with 'culture evenings' and support to attend places of worship
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot rated
safe: Preventing and controlling infectionNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Supporting people to eat and drink enough to maintain a balanced diet
Not rated
effective: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: End of life care and supportNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated