Date of assessment:29 October 2025 to 14 November 2025 Eunha Healthcare Ltd is a domiciliary care service providing the regulated activity personal care which is help with tasks related to personal hygiene and eating, in people's own homes. At the time of our inspection there were 101 people receiving personal care using the service. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. Where they do, we also consider any wider social care provided. We conducted this assessment to follow up on previous breaches of legal regulations relating to; safe care and treatment, staffing, fit and proper persons employed, duty of candour and good governance. At this assessment, we found some improvements had been made, and the provider had met the breaches of legal regulation in respect of safe care and treatment, staffing, fit and proper persons and duty of candour. However, some areas of improvement still remained, and the provider was still in breach of the legal regulation in respect of good governance. A new breach of legal regulation in respect of consent to care and treatment was also identified. The provider was responsive to all issues raised during this assessment, and the leadership team had a collective and positive approach to continuing to drive further improvements at the service. We have asked the provider for an action plan in response to the concerns found at this assessment.
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Eunha Healthcare Ltd received an overall rating of Requires Improvement, with Well-Led rated Inadequate, due to widespread governance failures including falsified audits, lack of provider transparency with CQC, unsafe staffing levels, medication errors, and persistent breaches of Regulations 12, 17, 18, 19 and 20. While people spoke positively about the caring attitude of staff and felt safe, systemic leadership and oversight failures—unchanged since the previous inspection in November 2022—resulted in Warning Notices being issued for Safe Care and Good Governance.
Concerns (10)
criticalStaffing levels: “we found calls where staff were logged in at 2 different people's addresses at the same time.”
criticalMissed or late visits: “staff had been 45 minutes late to support people... staff had stayed for less than half of the allocated time people had to receive their support.”
criticalMedication management: “a staff member had dispensed a person's medicines and left them in a pot next to the bed for the person to take when she arrived home. The staff member signed the MAR chart.”
criticalStaff training: “a staff member had no record of training for medicines awareness, falls awareness, health and safety and learning disability training.”
criticalGovernance: “The provider had falsely completed an audit of a person's daily notes... completing audits of the notes (which they were not in possession of) and recording there were no issues.”
criticalLeadership: “The provider failed to be honest and transparent with CQC... they told us they employed 35 staff at our initial inspection, but sent a training matrix to the local authority which contained 42 staff names.”
criticalRecord keeping: “Audits were not always effective as staff were auditing their own records... the daily care records were then audited by the same carer who made the error.”
criticalSafeguarding: “A person was assessed as lacking capacity around medicines... the person had full access to all their medicines, placing them at risk of significant harm.”
moderateCare planning: “a person's records stated the person had a walking frame, but another document stated there was no equipment used by this person.”
moderateConsent / capacity: “Mental capacity assessments had not been completed or were incomplete... people were not always able to make day-to-day choices about their lives.”
Strengths
· People and relatives said staff treated them with respect, dignity, and had a caring and friendly approach.
· Staff demonstrated understanding of safeguarding responsibilities and reported concerns to management appropriately.
· Staff wore PPE including aprons and gloves and described relevant infection control measures.
· People felt safe with staff; one person said staff ensured curtains were drawn and doors locked before leaving.
· Staff supported people with nutrition and hydration, providing encouragement and leaving snacks and drinks.
Quality-Statement breakdown (13)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidance (MCA)Requires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Assessing people's needs and choices; delivering care in line with standardsRequires improvement
well-led: Managers and staff being clear about their roles, quality performance, risks and regulatory requirementsInadequate
well-led: How the provider understands and acts on the duty of candourInadequate
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Continuous learning and improving care; promoting a positive cultureInadequate
Eunha Healthcare Ltd received an overall rating of Requires Improvement at its first inspection, with breaches of Regulations 17, 18 and 19 identified relating to governance failures, inadequate staff induction and training, and non-robust recruitment processes including delayed DBS checks. People and families reported a reliable, kind and caring service, but significant improvements were needed in staff oversight, medication record management and quality monitoring systems.
Concerns (8)
criticalStaffing levels: “Staff had commenced their employment, some working many months before a Disclosure and Barring Service (DBS) check had been carried out.”
criticalStaff training: “Staff training matrix had gaps showing some staff had not undertaken training in key topics related to people's safety such as infection prevention measures, safeguarding and health and safety.”
criticalGovernance: “The provider had failed to ensure sufficient systems and processes to monitor the safety and quality of the service provided were in place and were robust and effective.”
moderateSupervision / appraisal: “Staff were not always supported through supervision or had their competency assessed against measurable criteria to ensure they were providing good quality and safe care.”
moderateMedication management: “Medication administration records for a person had some missed staff signatures. This meant the provider could not be assured the person had received their medication as prescribed.”
moderateRecord keeping: “The registered manager had not audited people's medication administration records and was unaware staff were not always signing records.”
moderateSafeguarding: “Staff stated they would alert the registered manager to any concerns they had about potential abuse. However, they were not fully confident in all types and forms of abuse.”
moderateStaff competency: “There was no evidence as to the criteria used to determine staff's competency [in medicine management]. The provider's policy referred to staff being assessed; however it did not detail how.”
Strengths
· Family members described staff as kind and caring, with one stating 'The staff are very kind and caring.'
· Service was reported as reliable with staff arriving on time and staying the agreed length of care calls.
· People's needs were assessed before commencement and kept under review, involving people and family members in the process.
· Staff wore appropriate PPE including gloves, aprons and masks when providing personal care.
· People's care records were personalised, respectful and contained clear guidance for staff on individual needs and preferences.
Quality-Statement breakdown (21)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionGood
safe: Assessing risk, safety monitoring and managementGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Good
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
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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: Planning personalised care to ensure people have choice and control and to meet their needs and preferences; End of life care and supportGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; 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