Date of assessment: 30 September 2025 to 7 October 2025. Jigsaw Homecare Ltd is a domiciliary care service providing support to people of any age including those living with dementia living in their own homes. At the time of the assessment, the service was supporting 33 people with their personal care needs. Jigsaw Homecare Ltd was last rated requires improvement (published 19 August 2022). This assessment was undertaken due to age of the rating. An assessment has been undertaken of a specialist service that is registered for use by autistic people or people with a learning disability. At the time of the assessment, the service was not used by anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group. People received safe care from a small team of consistent staff members who knew them well. Where people were supported with medicines, this was done safely and records, such as medicine administration records, accurately reflected the support people received. Care plans were person centred and detailed how people wished to be supported. Where people needed support with specific conditions and/or equipment, care plans contained clear guidance for staff on how to support people and actions to be taken in the event of an emergency. Practical training such as medicines and manual handing were done in house by qualified staff members enabling the provider to refresh this training as needed, this included when new risks had been identified or when people needed new equipment. This ensured people received safe and effective care consistently. While audits and quality monitoring processes implemented by the registered manager were limited, care was found to be provided safely and inline with people’s wishes and we saw evidence of feedback being acted on quickly and effectively. This included sharing lessons learned with staff where needed.
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Jigsaw Homecare Ltd improved from Inadequate to Requires Improvement following a focused inspection against Warning Notices, with the service exiting Special Measures. However, continuing breaches of Regulation 12 (risk guidance deficiencies, catheter care, falls management) and Regulation 17 (incomplete records, missing MCA documentation) mean the service remains in breach and requires sustained improvement.
Concerns (6)
criticalCare planning: “lack of documented guidance for staff...some people were noted to be 'prone to falls', yet there were no identified associated risks”
criticalRecord keeping: “provider failed to ensure they kept accurate, complete and contemporaneous records in respect of each person”
moderateConsent / capacity: “People's records did not contain clear information about their capacity...no records of mental capacity assessments or best interest decisions”
moderateGovernance: “we identified that whilst they monitored call times on the live system there was no audit in place”
minorMedication management: “there remained very little information for staff, such as detailed protocols [for 'when required' medicines]”
minorStaff training: “Staff had not been trained specifically in the MCA, although this was covered in other modules of training they undertook”
Strengths
· Medicines administration improved; staff completed medicines training and had competency regularly checked
· Safe recruitment practices implemented with DBS checks carried out on all staff
· Safeguarding training completed; staff understood responsibilities to protect people and escalate concerns
· Call consistency improved; staff ring ahead if running late and calls are no longer being missed
· Supervision and appraisals now in place; staff feel supported by management
Jigsaw Homecare Ltd received a 'Requires Improvement' rating following a focused inspection of the Safe and Well-led key questions, with regulators identifying breaches of Regulations 12, 17, and 18 relating to unsafe medicines management, inadequate risk assessment, poor governance, and staffing deployment failures. The provider also failed to submit statutory notifications to CQC for 12 months and did not fully engage with post-inspection evidence requests.
Concerns (12)
criticalMedication management: “The provider did not complete any medication audits for the electronic records. This meant they were not aware or managing discrepancies with medicines.”
criticalCare planning: “People's safety needs associated with their health conditions were not always effectively assessed or detailed in their care plan. We found not all risks were recorded.”
criticalGovernance: “The provider failed to ensure their systems and processes to monitor people's care was effective and could not assure the Commission they had good governance systems in place.”
criticalStaffing levels: “One relative described a time due to the lack of staff their family member had been left without a lunch time call for a whole week.”
criticalIncident learning: “We were not assured all notifications for incidents, such as, falls with hospital admissions had been submitted to CQC. We had not received any notifications for the service for 12 months.”
moderateSafeguarding: “We found a number of incidents which were only discussed with an individual's social worker and not the safeguarding team. We were not assured the provider was following their own safeguarding policy effectively.”
moderateInfection control: “The providers infection control policy dated April 2020 had not been updated to include COVID-19.”
moderatePerson-centred care: “The terminology on some care plans were written in a derogatory way. For example, 'do not ask person what they want to eat just go in the kitchen and make it'.”
moderateConsent / capacity: “There was no best interest decision visible on documents we reviewed. We requested copies of best interest decisions from the registered manager with no response.”
moderateMissed or late visits: “Care was delivered at times in line with staff availability rather than people's choice.”
moderateRecord keeping: “Care plans shared with us had historic information in that was not relevant to the persons care needs at the time of the inspection.”
moderateLeadership: “The registered manager had no oversight of governance for the service...The registered manager said they did not know this had been implemented.”
Strengths
· Staff worked in partnership with other health and social care professionals.
· Systems were in place to investigate and monitor safeguarding concerns, with staff proactively raising concerns with the local authority.
· Changes to care practice were put in place when things went wrong, such as a new policy for hospital discharges.
· All people and relatives confirmed staff wore full PPE throughout the pandemic.
· People and families gave positive feedback about care staff, describing them as kind, friendly and respectful.
Jigsaw Homecare Ltd was rated Inadequate overall and placed in special measures following a focused inspection that found continued breaches in safe care, safeguarding, staffing and governance. Risk management, medicines, training, recruitment checks and oversight were all severely deficient, leaving 80 people receiving regulated care at increased risk of harm.
Concerns (20)
criticalMedication management: “Systems and processes in place were not effective to ensure people received their medicines safely.”
criticalMedication management: “People were being supported by staff who had no recorded medicines training.”
criticalMissed or late visits: “They are not coming at the correct times, I am left in bed for an average of 15 hours... They put me in bed at 6.30pm when I'd prefer to go to bed at 8pm.”
criticalCare planning: “People's care was not planned in a way to ensure their needs and preferences were being met.”
criticalStaff training: “Over half of the staff had not received infection control training at all, or not in the past five years.”
criticalStaff training: “We reviewed training records and found significant gaps in staff training.”
criticalStaffing levels: “The provider failed to ensure appropriate staffing was in place to meet people's preferred needs and to ensure people's safety.”
criticalSafeguarding: “People were not kept safe from the risk of abuse or neglect due to the lack of systems, processes and training in place.”
criticalSafeguarding: “Some staff we spoke with lacked a fundamental understanding of their safeguarding responsibilities.”
criticalIncident learning: “There was no system in place to learn from errors, as these were often not even identified, and there was no evidence of any improvements.”
criticalGovernance: “The provider failed to ensure effective oversight and robust governance which placed people placed at increased risk of harm.”
criticalLeadership: “widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
criticalPerson-centred care: “At management level we found evidence of a culture that significantly disregarded the needs of people.”
criticalRecord keeping: “The registered manager was unable to sufficiently demonstrate they had kept any records or taken any actions following incidents.”
criticalOther: “We reviewed recruitment records and found a lack of evidence that pre-employment checks were being carried out.”
moderateMissed or late visits: “How long they are there is a big issue at the moment. Carers only getting 30mins, instead of an hour.”
moderateCare planning: “One person's care plan contained brief information which indicated they had a catheter. However, there was no information to identify the associated risks”
moderateSupervision / appraisal: “I haven't had a supervision for 3 years.”
moderateCommunication with families: “I have never been involved in any care planning, I have never seen any care plans, I didn't get a reply to my emails with information.”
moderateInfection control: “During summer staff never wore PPE, they still never wear aprons, they only wear masks at my insistence. Staff don't change their gloves”
Strengths
· Provider was no longer in breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009 regarding notifications.
· Most people felt staff knew them well.
· Most staff felt they could ring the office when needed.
Quality-Statement breakdown (8)
safe: Assessing risk, safety monitoring and management; Preventing and controlling infectionInadequate
safe: Using medicines safelyInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Learning lessons when things go wrongInadequate
well-led: Promoting a positive culture; Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Engaging and involving people using the service, the public and staffInadequate
well-led: Duty of candour; Continuous learning and improving care; Working in partnership with others