Caremark Hounslow is a domiciliary care agency. It provides personal care to people living in their own houses and flats. The agency is registered to care for adults and children including people with a learning disability. At the time of our assessment, 47 people were receiving support with personal care. The agency provided additional support to others including companionship. The agency was a franchise. The registered provider operated this and 1 other care agency branch. The assessment started on 10 April 2025 and ended on 17 April 2025. We made telephone calls to people using the service, their relatives and staff. We met the registered manager via a video call, and we reviewed records remotely. The last rating of this service was requires improvement (published 16 November 2022) when we identified breaches relating to safe care and treatment and good governance. We told the provider to make improvements. This assessment was conducted to follow up on their action plan. We found improvements had been made and the service is now rated good. We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it. We found the provider was meeting the principles of right support, right care, right culture. Staff provided safe care which met people’s needs. Risks to people’s safety were assessed and planned for. Some people were supported to learn new skills and spend time outside of their homes attending schools, colleges and leisure facilities. The provider had assessed the risks associated with these to help keep people safe. There were enough staff to provide care. People were cared for by the same familiar members of staff who they liked. The staff undertook a range of training, including specialist training to help them understand about people’s needs and caring for people with a learning disability. People thought the staff were kind, caring and polite. Staff felt well supported and enjoyed working for the agency. The provider had effective systems to monitor and improve the quality of the service. They asked stakeholders for feedback and were involved in initiatives to help support local communities.
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Caremark Hounslow's first inspection resulted in an overall 'Requires Improvement' rating, with regulatory breaches found under Regulation 12 (safe care and treatment) and Regulation 17 (good governance) due to inadequate risk management plans, failure to identify lessons from incidents and safeguarding concerns, and insufficiently robust quality assurance processes. The service demonstrated strengths in medicines management, staff recruitment, infection control, and person-centred caring interactions, with the 'Caring' domain rated 'Good'.
Concerns (9)
criticalCare planning: “When a person had been identified as living with a medical condition the provider had not developed a risk management plan providing guidance for care workers.”
criticalIncident learning: “The provider had not consistently identified any lessons learned from these or preventative measures which were taken to reduce the risk of reoccurrence.”
criticalGovernance: “Sections covering care plans checks, safeguarding, incidents and accidents, complaints and compliments and late or missed visits had not been completed.”
criticalSafeguarding: “Two of the records did not include any investigations into the cause of the incidents and any lessons which could be learned to reduce the risk of reoccurrence had not been identified.”
moderateConsent / capacity: “The mental capacity assessment for another person indicated that they were not able to make decisions about their care, but the assessments which were completed were generic.”
moderateComplaints handling: “The provider did not always identify when actions were completed and preventative measures to reduce the risk of a similar concern occurring again.”
moderateRecord keeping: “The providers medicines audit did not provide information to ensure the MAR charts were completed accurately and people's medicines were administered as prescribed.”
minorPerson-centred care: “Care plans did not always identify a person's preferences for food and drink, but care workers were advised to ensure each person was given a choice.”
minorEnd-of-life care: “Care plans we reviewed did not include any information on the person's end of life care wishes.”
Strengths
· Medicines were administered as prescribed and safely managed, with completed MAR charts and staff trained in medicines administration.
· Robust recruitment process including two references, full employment history, right to work checks, and DBS checks.
· Care workers were kind and caring; relatives confirmed family members were treated with dignity and respect.
· People's religious and cultural beliefs were identified and incorporated into care plans.
· Care plans were person-focused, identifying individual needs, communication requirements, and personal history.
Quality-Statement breakdown (23)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Good
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 to provide consistent, effective, timely careGood
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
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: End of life care and supportNot rated
well-led: Continuous learning and improving careRequires improvement
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