Date of assessment: 3 to 6 March 2026. Majestic Care North West Limited provides care to people in their own homes. The service is registered to support older people, younger adults, people living with dementia, people with mental health needs, people who misuse drugs and alcohol, people with sensory impairment needs, people with a learning disability or autistic spectrum disorder, and people with a physical disability. The provider had a good learning culture and people could raise concerns. People were protected and kept safe from the risk of abuse. Staff understood and managed risks. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. People had enough to eat and drink to stay healthy. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. They monitored people’s health to support healthy living. Staff made sure people understood their care and treatment to enable them to give informed consent. People were treated with kindness and compassion. Staff protected their privacy and dignity. People had choice in their care and were encouraged to maintain relationships with family and friends. Staff responded to people in a timely way. The provider supported staff wellbeing. People were involved in decisions about their care. Staff provided information people could understand. People knew how to give feedback and were confident the provider took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. Staff worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
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Majestic Care North West Limited achieved a Good rating across all five key questions at this announced inspection on 31 January and 1 February 2018, demonstrating significant improvement from the previous inspection in July 2016 when breaches of Regulations 16, 17, 18 and 19 were identified. Minor areas for improvement remained around risk assessment detail, medicines recording, staff competency documentation, person-centred care planning and formalisation of governance oversight, all of which the management team was actively addressing.
Concerns (6)
minorRecord keeping: “records of alerts made to the local authority and notifications sent to CQC were not stored together”
minorCare planning: “some of the assessments with regards to skin integrity, nutrition and mobility, needed further detail to ensure any changes to people's health and wellbeing were promptly recognised”
minorMedication management: “medicine management procedures needed to be further developed to reflect current practice...some gaps in the recording on the old system”
minorStaff competency: “'shadowing' arrangements for new staff were not clearly recorded and did not demonstrate that their competence was assessed prior to working unsupervised”
minorPerson-centred care: “people's preferences for male or female staff support, ethnicity and sexual orientation was not recorded in their care documentation which meant people's needs may not be fully met”
minorGovernance: “systems to monitor the manager's practice and the day to day running of the agency were not formalised and did not fully evidence the provider's oversight of the service”
Strengths
· People consistently felt safe, trusted staff implicitly, and described staff as 'like family'
· Sufficient staffing levels with flexible deployment and consistent care teams allocated to individuals
· Improved recruitment procedures with full DBS checks, references and proof of identity in place
· Staff received wide-ranging mandatory training, regular supervision, appraisal and ongoing support
· People were involved in care planning, reviews and decision-making about their support
Majestic Care North West Limited was rated Requires Improvement overall following a July 2016 inspection, with four regulatory breaches identified covering recruitment (Reg 19), staff training (Reg 18), complaints handling (Reg 16), and governance (Reg 17). The service demonstrated genuine caring values and adequate staffing, but systemic failures in quality oversight, safeguarding record-keeping, mandatory training completion and complaints management posed risks to people's safety and wellbeing.
Concerns (10)
criticalSafeguarding: “We found there were no records kept of the matters raised, however during the inspection the registered manager introduced a process to support the recording, managing and responding to safeguarding incidents.”
criticalStaff training: “gaps in the records which indicated staff had not completed the provider's mandatory training programme...lack of training in manual handling, safeguarding people, medicines management and MCA 2005.”
criticalComplaints handling: “no information to demonstrate how the complaints had been investigated, followed up and responded to...no records of acknowledging receipt of the complaints.”
criticalGovernance: “lack of the quality monitoring and auditing processes to ensure the service is operated safely and effectively...breach of Regulation 17 of The Health and Social Care Act 2008.”
criticalRecord keeping: “one person's application form was missing...A reference from a previous employer had not been obtained...breach of Regulation 19.”
moderateStaff competency: “'shadowing' arrangements for new staff did not include a structured assessment of their competence in their role prior to working unsupervised.”
moderateMedication management: “hand written entries on the MAR charts had not been counter signed as correct...gaps on one MAR chart which meant it was not clear if the person had been supported with their medicines.”
moderateCare planning: “some risk assessments were lacking in detail...lack of routine assessing of risks associated with skin integrity, malnutrition and falls, in accordance with current recognised guidance.”
moderateIncident learning: “no processes in place to monitor and assess complaints, the action taken and lessons learned to make improvements...no records of management meetings being held.”
minorConsent / capacity: “staff spoken with indicated a lack of awareness of the MCA and said they had not yet accessed the training.”
Strengths
· People consistently reported feeling safe and expressed satisfaction with the service, with comments such as 'They are keeping me safe I will vouch for that.'
· Staff demonstrated caring attitudes and promoted people's dignity, privacy and independence, receiving positive feedback including 'They are caring and really helpful.'
· Sufficient staffing levels were maintained with an on-call system, and people confirmed visits were rarely missed or late.
· A small consistent team of carers was assigned to each person, supporting familiarity and personalised care.
· A digital app care planning and recording system had been introduced to improve real-time recording and information sharing.
Quality-Statement breakdown (17)
safe: Recruitment proceduresRequires improvement
safe: Safeguarding recording and managementRequires improvement
safe: Staffing levelsGood
safe: Medicines managementRequires improvement
safe: Risk assessmentRequires improvement
effective: Staff training and inductionRequires improvement