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Date of Assessment: 02 to 17 October 2025. This was an assessment covering all 5 key questions. This assessment was prompted by a review of the information we held about the service. This was our first assessment of the service since the provider registered with CQC in February 2023. The service is a care at home service providing support to older and younger people living in their own homes. Not everyone who used the service were receiving the regulated activity of personal care. Personal care is help with tasks related to personal hygiene and eating. At the time we started our assessment; they were providing personal care services to 73 people. The provider lacked effective governance in relation to monitoring and improving quality and safety. This had resulted in shortfalls in the registered manager’s oversight of the service and issues related to care visit l monitoring, medicines administration, incident and safeguarding reporting, care planning and auditing key areas of the service. This led to instances where people did not receive the care they needed, when they needed it. People told us they had received an inconsistent experience of receiving care. The provider did not always comprehensively plan how to make improvements to the service when issues had been found. The provider did not always collaborate effectively with stakeholders to promote positive outcomes for people or improve safety. Staff record keeping in relation to key areas of care was not consistent and did not evidence how risks were managed, or shortfalls addressed. However, the registered manager was receptive to CQC’s feedback and has taken steps to make initial changes to improve safety and quality. There were enough staff in place to meet people’s needs, but the provider did not always ensure they had effective oversight of staff’s ongoing training requirements. This resulted in staff not always receiving timely training updates. People told us they received consistent staff whom they had positive working relationships with. People said staff understood their needs and treated them with dignity and respect. However, when regular staff were absent, people told us the temporary replacements were not as familiar with their needs or motivated in their role. People told us improvements were needed around how effectively the provider communicated with them about their care. They told us they were not always informed about changes to their care or changes to the staff allocated. However, people told us they felt staff were responsive to their needs. People told us they were involved in planning and reviewing their care. The service 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. The provider was in breach of 1 legal regulation relating to good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.
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