Dates of assessment: 7 January to 27 January 2026. Vision Care Services is a domiciliary care agency, providing care and support for adults and children living in their own homes. At the time of our assessment the service was supporting 154 people with personal care. This included 3 people with a diagnosis of a learning disability. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. The inspection was announced, and we visited the office on 14 and 21 January 2026.We carried out this assessment to check the provider had made the required improvements after our last assessment of the service. Safe staffing levels were in place and staff had the training and support to carry out their role. Recruitment was managed safely. There was an established staff team who knew people well and fostered caring and trusting relationships. Call times were well organised and flexible to meet people’s needs and preferences. The service had a positive person-centred culture and demonstrated they learnt lessons when things when went wrong. Risks to people’s health, safety and wellbeing were assessed and regularly reviewed. Medicines were managed safely. People’s needs were assessed before they started using the service. Some improvements were required relating to records to assess people’s capacity. The provider responded promptly to this and took action. Staff demonstrated a good understanding of the principles of capacity and consent. Audits and checks were in place to maintain oversight of the service. There was a cohesive, strong management team and their roles were clear and well organised. The provider and registered manager were accessible and approachable and committed to providing a high-quality service. The service worked in partnership with community groups and stakeholders. The provider was previously in breach of legal regulations in relation to good governance, the management of risk and medicines, and staff training. Improvements were found at this assessment, and the provider was no longer in breach of legal regulations. We found the overall quality of the service had improved and the rating had changed from requires improvement to good.
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Vision Care Services (Bradford) was rated Requires Improvement overall following a November 2023 inspection, with regulatory breaches identified in medication management, risk assessment, staff training, and governance. The service demonstrated strong person-centred culture and positive feedback from people and relatives, but ineffective audit systems failed to identify safety shortfalls prior to inspection.
Concerns (6)
criticalMedication management: “PRN protocols were not in place where required for 5 people. The provider did not have a system in place for staff to record and monitor 4-hour gaps required between administration of paracetamols.”
criticalCare planning: “5 lacked specific guidance on how staff should provide person centred care in relation to people's health risks. For example, there was a lack of information for staff on how to manage people with epilepsy.”
criticalStaff training: “Most staff did not have epilepsy, diabetes or stoma care training, despite providing care to people with these conditions.”
criticalGovernance: “The provider did not have effective audits in place to monitor and review the effectiveness or the safety of the service. We identified shortfalls in medicines, calls times, record keeping and training.”
moderateIncident learning: “We were not assured the system for learning lessons were effective because audits had not consistently highlighted where improvements were needed.”
moderateRecord keeping: “Provider audits were not effective and failed to identify any of the issues we found on inspection.”
Strengths
· People and relatives provided overwhelmingly positive feedback; one person said 'I have found the carers to be brilliant. They have given me my life back.'
· Staff felt well cared for, listened to, and valued by the provider and management team.
· Safe and effective recruitment process with thorough pre-employment checks for all staff.
· Effective safeguarding systems in place; staff knew how to report and raise concerns.
· Provider was proactive in gaining feedback from people, relatives and staff through regular engagement including monthly coffee mornings.
Quality-Statement breakdown (9)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff
Vision Care Services received an overall rating of Requires Improvement following a June 2017 inspection, with two regulatory breaches identified: unsafe medicines administration recording (Regulation 12) and insufficiently robust governance systems that failed to detect staff leaving visits early (Regulation 17). The service demonstrated strengths in caring, responsiveness, staff training, and safeguarding, but must urgently address medication management and visit-time monitoring to ensure people consistently receive safe, contracted care.
Concerns (7)
criticalMedication management: “Gaps and inconsistencies in the recording meant the registered provider could not evidence people received their medicines as prescribed.”
criticalMedication management: “MARs did not indicate where medicines were prescribed as and when required (PRN) and the dose which should be offered. We saw there were no completed PRN protocols in place.”
criticalMissed or late visits: “We saw examples of staff staying between 15 and 25 minutes for visits which were scheduled for 30 minutes.”
criticalGovernance: “These systems were not effective in identifying some of the areas of concern we found during this inspection as they had either not been recognised or not sufficiently responded to.”
moderateGovernance: “The management team were using a social media service to communicate messages containing sensitive information...had not complied with the Data Protection Act (1998).”
moderateIncident learning: “They made us aware of nine deaths which were expected. The nominated individual said, 'We've not reported them because they were expected deaths.'”
moderateRecord keeping: “Daily notes were recorded in hard back A4 notebooks...We looked at one record and saw it contained seven months of information before it had been returned to the office.”
Strengths
· People and relatives felt safe receiving the service; staff had received safeguarding training and knew how to recognise and report abuse.
· Care plans were individualised, person-centred, and contained relevant up-to-date information with evidence of regular reviews.
· Staff received appropriate induction including the Care Certificate, ongoing supervision every three months, and annual mandatory training.
· Recruitment procedures were safe with identity checks, references, and DBS checks in place.
· People and relatives were highly complimentary about staff caring attitudes, privacy, dignity, and responsiveness to needs.
Vision Care Services achieved a Good rating across all five key questions at the October 2018 inspection, demonstrating significant improvement from the previous Requires Improvement rating. The service addressed prior breaches in medicines management and governance, with only minor recording gaps identified.
Concerns (3)
minorMedication management: “We did find one MAR chart which had not been consistently completed.”
minorRecord keeping: “We did note there was no provision on the interview record to demonstrate any 'gaps' in employment had been explored.”
minorSupervision / appraisal: “Staff were supported by the registered manager and received formal supervision where they could discuss their ongoing development needs, although these needed to be more regular.”
Strengths
· Medicines management improved since previous inspection; staff trained and competency checked via observed practice.
· Sufficient staffing levels with well-organised rotas minimising travel time and promoting continuity of care.
· People and relatives consistently described staff as kind, gentle, caring and compassionate.
· Care plans were detailed, person-centred and regularly reviewed, reflecting individual needs, preferences and life histories.
· Strong end-of-life care provision, working closely with district nurses and palliative care teams.
Good
well-led: Working in partnership with othersGood
effective: Healthcare access and nutrition
Good
caring: Staff attitudes and person-centred approachGood
caring: Privacy, dignity and equalityGood
responsive: Care planning and reviewsGood
responsive: Complaints handlingGood
well-led: Audit and governance systemsRequires improvement