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Dates of Assessment: From 15 to 28 October 2025. This included 2 visits to the office on 15 and 16 October 2025. Headquarters BC Care is a domiciliary care agency supporting people with personal care living in their own homes. This was the first assessment for this service, and we carried out the assessment in response to information of concern we had received about the service. At the time of this assessment, there were 4 people receiving the regulated activity of personal care from the service. During the assessment, we found systems and processes for managing people’s care and medicines were not fully embedded, which limited guidance for staff and oversight. Care plans generally contained some personal information, but gaps in risk assessments and clinical guidance meant staff could not consistently respond to people’s health needs. Monitoring tools for behaviours and high-risk medications were not in place, and communication with external professionals was limited. People were supported to make choices and maintain independence, with staff providing care in ways that respected personal preferences, dignity, and cultural needs. Staff demonstrated kindness and compassion, but some documentation did not consistently reflect respectful, person-centred language. Staff reported high morale and adequate training but had limited supervision, spot checks, or opportunities to contribute to service development. Governance systems were weak, audits and feedback were not fully used to drive improvement, and the provider could not demonstrate oversight of workforce compliance, quality, or regulatory requirements. Partnership working with other services was minimal, and the involvement of people, relatives, and staff in shaping the service was limited. Similarly, learning and innovation were not embedded, with few systems in place to evaluate performance or ensure continuous improvement. Overall, while care delivery demonstrated some positive outcomes, the service required improvement in monitoring, governance, staff support, and consistent person-centred practice to ensure people received safe, responsive, and effective care. We found the provider was in breach of 3 legal regulations at this assessment in relation to safe management of medicines, good governance and safe staffing. We have asked the provider for an action plan in response to the concerns found at this assessment.
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