The date of the assessment was from 20 to 22 August 2025. Master Quality Health Care Service is a domiciliary care service providing personal care for people who live in their own homes. At the time of our assessment the service supported 12 people. This assessment was triggered to follow up on concerns found at the previous assessment. We visited the service on 20 August 2025. We looked at records relating to the management of the service. Following the visit, we spoke on the telephone with people, relatives and staff. The overall rating for this assessment is good. At the last assessment we found concerns relating to quality assurance and monitoring systems which were often not effective. We made a recommendation about the documentation of medicines. At this assessment improvements had been made in relation to identifying and monitoring risk, and record keeping. Medicines were managed safely, and records were accurate and up to date. There were enough staff to meet people’s needs and support them safely. Staff were kind, compassionate and knew people well. There was effective leadership and oversight of the service. Staff spoke positively about the management team. They told us management provided support with learning and development opportunities and promoted an open and inclusive culture.
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First inspection of this newly registered domiciliary care agency rated Requires Improvement overall, driven by gaps in risk assessments, medicines documentation and ineffective quality assurance audits. Effective, caring and responsive domains were rated Good, with strengths in recruitment, staff training, safeguarding awareness and a positive, person-centred culture.
Concerns (9)
criticalCare planning: “Risks to people were not always identified. Risk assessments were not always carried out for medicines, falls and moving and handling.”
criticalGovernance: “The provider's quality assurance systems and processes were not always effective. Although some audits were in place, they had not enabled the provider to identify and address the shortfalls”
moderateCare planning: “their moving and handling risk assessment did not identify the potential risks of using these mobility aids and there was no guidance in place for staff”
moderateCare planning: “Some people were at risk of falls; there were no falls risk assessments in place or guidance for staff on how to minimise these risks.”
moderateMedication management: “The provider's medicines management systems were not always safe.”
moderateMedication management: “Where staff support was required, this was not always clearly recorded... the audit tool used was too basic to able to identify any issues.”
moderateRecord keeping: “shortfalls in the quality of record keeping we found at this inspection. This included the assessment of risks to people, the robustness of needs assessments, medication audits and reviews of care plans.”
minorCommunication with families: “one person did not have English as a first language... Service information had been provided, but only in English and not in their first language.”
minorPerson-centred care: “Care plans were person centred but required more detail.”
Strengths
· Robust recruitment processes including DBS, identity and reference checks
· Sufficient staffing levels with call monitoring system to identify late or missed calls
· Staff trained in safeguarding and confident in reporting concerns
· Staff received inductions linked to the Care Certificate and ongoing training
· Regular supervision and spot checks supporting staff
Quality-Statement breakdown (25)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk from abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot 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: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Continuous learning and improving careNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated