Date of assessment: 4 February - 24 February 2026. Blue Ribbon Community Care in South West London Care Quality Services is a homecare agency mainly supporting older people with physical disabilities with some people living with dementia. At the time of our assessment there were six people using the service. We undertook this assessment as it had been over 5 years since our last visit. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. At the time of the assessment, the service was not supporting any autistic people or people with a learning disability, but the provider had regard to underpinning principles of ‘Right support, right care, right culture’. Staff had undertaken relevant training. Suitable policies and procedures were in place. People and their relatives consistently described positive experiences, highlighting reliable, compassionate staff who understood their needs well. Feedback showed people felt safe, respected and confident in the service being delivered. The culture of safety was well embedded. Staff understood how to recognise and report safeguarding concerns, telling us they followed policies and procedures and escalated issues when needed. Records evidenced incident reporting, analysis and learning. The registered manager confirmed learning was shared through meetings and digital communication, so staff were consistently updated. Risks were clearly described in people’s care plans, with instructions for how staff should reduce or manage them. Care was tailored to people’s individual needs and preferences. Staff were described as kind, respectful and supportive, building strong relationships with people over time. The service was responsive and continually improving. People said they could contact the manager easily and felt listened to. Routine surveys were analysed and used to make service improvements. Communication with health and social care professionals was clear and effective, ensuring coordinated and consistent care during transitions or changes in need. Leadership was strong, visible and well-regarded. Relatives described the service as well managed and supportive. Documents also demonstrated effective governance systems, including regular audits which identified issues and drove improvements. Overall, the provider delivered consistent, safe and person centred care, supported by strong leadership, effective oversight and a culture focused on improvement and positive outcomes.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-1828527691.
Blue Ribbon Community Care in South West London improved from Requires Improvement to Good across all five key questions, having fully addressed previous regulatory breaches in risk management, medicines records, care planning, staff training and governance. One recommendation was made regarding the recording and management of informal concerns, and end-of-life care training for staff was outstanding at the time of inspection.
Concerns (2)
minorComplaints handling: “informal concerns people made were not recorded...no record of action the provider told us they had taken in response to people who had raised concerns about staff time keeping”
minorEnd-of-life care: “Staff had not received any end of life care training, although the managing director showed us recorded evidence that confirmed dates had already been arranged for all staff”
Strengths
· Provider successfully addressed all previous breaches from the prior inspection, improving ratings across four of five key questions from Requires Improvement to Good.
· People and relatives consistently reported high satisfaction, with staff described as kind, caring and punctual.
· Strong medicines management: staff trained and competency-assessed, MAR sheets routinely audited, and unannounced spot checks carried out.
· Person-centred care plans updated to reflect individual preferences, strengths, likes/dislikes and communication needs.
· Robust electronic monitoring systems (ECM and training-tracking) used to proactively identify and address quality issues.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
Blue Ribbon Community Care in South West London was rated Requires Improvement overall following an April 2018 inspection, with breaches of Regulations 17 and 18 identified relating to the absence of quality assurance audits, incomplete risk assessments and care records, unsigned MAR sheets, and staff lacking up-to-date training including in safeguarding, medicines management and the Mental Capacity Act. The service was rated Good for caring, with people and relatives consistently praising staff as kind, respectful and supportive of independence.
Concerns (10)
criticalRecord keeping: “people's medicine administration records (MAR) were not always signed for when either staff or relatives had administered medicines to people”
criticalGovernance: “Quality assurance audits were not carried out to identify, review and make improvements required to ensure people's safety”
criticalStaff training: “some staff had not had a refresher training in safeguarding, medicines management and infection control since 2012”
criticalCare planning: “risk assessments carried out by the service did not always provide details on the actual risks to people”
moderateCare planning: “a person had 'Type 2 Diabetes'. There was no other information available for staff to follow when supporting this person”
moderateMissed or late visits: “We never know what time", "I do have concerns as [staff] do not arrive on time and [the relative] is left waiting for most of the morning”
moderateSupervision / appraisal: “staff had not received regular one-to-one support through supervision and appraisal meetings”
moderateStaff competency: “Two out of three staff we talked to had a very limited knowledge about the Mental Capacity Act 2005 (MCA)”
moderateConsent / capacity: “mental capacity assessment completed by the service which lacked information on how it was decided that the person had lacked capacity”
moderateMedication management: “One of the MAR sheets had a number of instances when the medicines were not signed for”
Strengths
· People felt safe with staff and reported staff were caring, friendly and patient
· Pre-employment checks including references and DBS were consistently undertaken
· Staff promoted people's independence and respected their dignity and privacy
· People and relatives were involved in developing and consenting to care plans
· Management team was approachable and responsive to people, relatives and staff
Quality-Statement breakdown (18)
safe: Risk managementRequires improvement
safe: Medicines managementRequires improvement
safe: SafeguardingGood
safe: RecruitmentGood
effective: Staff training and developmentRequires improvement
effective: Supervision and appraisalRequires improvement
effective: Timekeeping and communicationRequires improvement
Blue Ribbon Community Care in South West London received a Good rating across all five key questions at its first inspection following relocation, with inspectors finding safe staffing, effective training, and person-centred practices throughout. Minor concerns were noted around consistency of carer matching, call timing reliability, and occasional gaps in care plan awareness for some people using the service.
Concerns (4)
moderatePerson-centred care: “one person said, 'I have cancelled some care completely as over an hour & a half late and sometimes no one has turned up.'”
minorCommunication with families: “One relative said, 'I do ring the office with my concerns but feel they are keen to get me off the phone.'”
minorCare planning: “one person said, 'I have had carers coming for 3 years now, they are absolutely wonderful but I don't have a care plan.'”
minorStaff competency: “A relative said, 'occasionally some carers are not up to standard, some don't seem to understand dementia clients and building a relationship.'”
Strengths
· Robust DBS-checked recruitment process with scenario-based interviews and 12-week probationary period
· Comprehensive induction based on the Care Certificate, with ongoing mandatory annual training including dementia and end of life care
· Medicine administration safely managed, trained staff, records audited and kept up to date
· Person-centred care plans that were individualised, regularly reviewed and updated as needs changed
· Effective quality assurance system including spot checks, phone contact, file audits and regular care reviews
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
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 meet people's needs, preferences, interests and give them choice and controlGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Continuous learning and improving careGood
well-led: Planning and promoting person-centred, high-quality care and support with openness; duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood
well-led: Working in partnership with othersGood
effective: Nutrition and health needs
Good
caring: Staff attitude and compassionGood
caring: Promoting independence and choiceGood
responsive: Care planningRequires improvement
responsive: Person-centred supportGood
responsive: Complaints handlingGood
responsive: End of life careGood
well-led: Quality assurance and governanceRequires improvement
well-led: Leadership and managementGood
well-led: Information sharing and communicationGood