Date of assessment: 9 March to 13 March 2026 . Naidcare provides personal care and support to people who require assistance in their own home. This service is a domiciliary care agency. At the time of our assessment 4 people were being supported by the service. 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. We received concerns in relation to staff training, care plans and risk assessments and governance. As a result, we undertook a responsive assessment to review the key questions of safe and well-led only. We found breaches of regulations in relation to good governance, staffing and fit and proper persons employed. The governance arrangements did not always provide assurance the service was well led. Quality assurance systems were not robust and had not identified the shortfalls we found during our inspection. Suitable arrangements were not in place to ensure all staff employed were safely recruited. The nominated individual was managing the service in the absence of a registered manager. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We have asked the provider for an action plan in response to the concerns found at this assessment.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-4288901167.
Naidcare improved from Requires Improvement to Good following a focused inspection of Safe and Well-Led domains, with the provider no longer in breach of Regulations 17, 18 or 19. The service demonstrated effective staffing, safe medicines management, robust governance, and a caring, person-centred culture.
Strengths
· No missed or late calls recorded; electronic call monitoring system confirmed consistent visit delivery
· Very low staff turnover enabling continuity of care and strong rapport between staff and people
· Medicines competency assessments introduced since last inspection, with regular medicine audits completed
· Robust recruitment checks in place including DBS, references, identity verification and interviews
· Registered manager approachable and well-regarded by both staff and relatives
Naidcare received a Requires Improvement rating for the second consecutive inspection, with breaches of Regulations 17, 18 and 19 identified relating to poor governance, insufficient staffing oversight and inadequate recruitment checks. A Warning Notice was served for the governance breach, while significant concerns remained around medicines management, incomplete safeguarding investigations and ineffective quality assurance systems.
Concerns (10)
criticalStaffing levels: “195 calls out of 1126 for June and August 2022 were more than 45 minutes late. There were 48 calls which were not logged despite the provider having an automated system”
criticalGovernance: “Governance arrangements were not robust and effectively managed. This placed people at risk of harm. A Warning Notice was served”
criticalStaff competency: “A full employment history was not sought for all newly employed members of staff. Two written references were not received for three members of staff prior to commencing in post.”
criticalSafeguarding: “Internal investigations were not commenced or completed in response to the allegation of harm to ensure lessons were learned and improvements made when things go wrong.”
moderateMedication management: “'No outcome' was recorded, giving no indication if the person had received their medicines or not. Medication audits were not being undertaken.”
moderateStaff competency: “Staff had received medication training but had not had their competency assessed through direct observation to ensure their practice was safe.”
moderateSupervision / appraisal: “Robust induction arrangements were not in place for all staff. Not all staff had received regular supervision or spot check visits.”
moderateCommunication with families: “If you try to contact [Naidcare] I wouldn't be able to, based on previous attempts as there is no voicemail, it just rings.”
moderateIncident learning: “142 calls recorded staff were logged in at two locations at the same time and 351 had no staff travel time included. This had not been picked up by the provider or registered manager.”
minorRecord keeping: “A written record was not completed or retained for two members of staff to demonstrate the discussion taken place as part of the interview process.”
Strengths
· People said they felt safe and had no concerns about their safety or wellbeing when staff visited them.
· Staff had access to appropriate PPE and relatives confirmed staff always wore PPE during visits.
· Staff were complimentary of the registered manager and felt supported in their roles.
· People and relatives considered the service to be well run and expressed confidence in raising concerns.
· The service demonstrated working in partnership with the Local Authority and other healthcare professionals.
Quality-Statement breakdown (9)
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Preventing and controlling infectionGood
well-led: Promoting a positive culture; Duty of candour; Continuous learning and improving careRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirements
Naidcare received an overall rating of Requires Improvement at this April 2021 focused inspection, with ongoing concerns around risk assessment specificity, medication competency assessments, incomplete recruitment checks, and an unregistered manager. While improvements since the 2019 inspection resolved previous regulatory breaches in governance, staffing training, and person-centred care, persistent gaps in leadership oversight and safety practices meant the service remained rated Requires Improvement for the second consecutive inspection.
Concerns (8)
criticalStaff competency: “Staff had received medication training but had not been assessed as competent before being involved in the administration of medicines.”
criticalGovernance: “The manager was not registered with the Care Quality Commission. The manager confirmed an application to register with us had been forwarded but upon checking our records this had not been received.”
moderateCare planning: “further information was required to demonstrate how risks to a person's wellbeing and safety were to be mitigated and to ensure these were individualised, person-centred and not generic.”
moderateStaff training: “A member of staff had commenced the 'Care Certificate' but this had not been completed despite having been employed since June 2020 and having had no previous experience in a care setting.”
moderateRecord keeping: “gaps in employment not explored for one member of staff, no evidence of an Adult First Check for one member of staff and no evidence of interview records for two staff members.”
moderateLeadership: “the manager was unaware of the improvements still required relating to recruitment, ensuring staff had completed medication competency assessments and that the completion of the Care Certificate remained incomplete.”
minorCommunication with families: “some relatives expressed concern that not all telephone calls were returned or returned in a timely manner.”
minorPerson-centred care: “when an unfamiliar staff member was required to provide support due to staff annual leave or sickness, neither the person using the service or their relative was forewarned in advance.”
Strengths
· Low incidence of safeguarding concerns; all investigated in conjunction with the Local Authority.
· Suitable staffing numbers in place and electronic system used to monitor missed and late calls.
· People received medicines as prescribed with accurate MAR records and suitable audit arrangements.
· Staff received induction, formal supervision and regular spot checks.
· People's healthcare and nutritional needs were promptly met.
Quality-Statement breakdown (17)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
Naidcare received a 'Requires Improvement' rating across all five key questions at its August 2019 inspection, representing a deterioration from its previous 'Good' rating, with four regulatory breaches identified covering safe care and treatment, person-centred care, staffing, and governance. Key failures included unsafe medication administration, missing care plans, undertrained staff, ineffective governance systems, and a task-focused rather than person-centred approach to care delivery.
Concerns (15)
criticalMedication management: “The MAR for three people showed there were numerous gaps on the MAR form. There was nothing to demonstrate if the person's medication had been administered or omitted.”
criticalMedication management: “The MAR form for one person in May 2019, showed they did not receive all of their prescribed medication in line with the prescriber's instructions. This referred specifically to an antibiotic medication.”
criticalStaff training: “Not all staff had evidence of up-to-date medication training. Staff's competency to administer medication was not assessed.”
criticalStaff competency: “Not all staff were comfortable and felt able to competently support this person effectively. Online training relating to this person's medical condition was only provided to staff following our enquiry.”
criticalCare planning: “Two out of five care files viewed did not have a support plan in place detailing all aspects of a person's individual circumstances and needs.”
criticalGovernance: “Effective governance and quality assurance arrangements were not in place to assess, monitor and improve the quality and safety of the service provided.”
moderateStaff training: “No information available to demonstrate the registered manager or the other trainer had attained a 'train-the-trainer' qualification.”
moderateMissed or late visits: “People told us there had been many occasions where staff were late. One person told us, 'If staff run late, it is usually about 15 to 20 minutes. There are odd occasions when it has been beyond 30 minutes.'”
moderateRecord keeping: “A record of the assessment had not been maintained by the field supervisor.”
moderatePerson-centred care: “People's comments suggested staff primarily focused on tasks rather than the people themselves. People told us they wanted staff to spend time with them, sit and talk, but this rarely happened.”
moderateCommunication with families: “There was a lack of evidence to demonstrate how the service assessed people who had a disability, impairment or sensory loss to receive information they can access and understand.”
moderateIncident learning: “Suitable arrangements were not in place to evaluate and review people's MAR forms to enable lessons to be learned.”
moderateLeadership: “Not all staff in key positions understood their roles and responsibilities. There was no documented evidence to demonstrate the improvements required and how their performance was to be effectively managed.”
minorSupervision / appraisal: “Where negative comments were made, these consistently related to staff not wearing their uniform or identification badge. No information was recorded detailing how these issues were to be monitored and addressed.”
minorConsent / capacity: “Improvements were required to ensure people's capacity to make decisions was clearly recorded.”
Strengths
· Risk assessments were in place for moving and handling needs and environmental risks.
· Staff understood safeguarding procedures and had received up-to-date safeguarding training.
· Staff wore appropriate PPE including aprons and gloves when providing care.
· People confirmed no missed calls where staff failed to attend.
· Staff received induction, supervision including spot-check visits, and had completed the Care Certificate.
Quality-Statement breakdown (24)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Good
well-led: Working in partnership with othersGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
well-led: Promoting a positive culture; continuous learning and improving careRequires improvement
well-led: Managers and staff being clear about their roles and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Working in partnership with othersGood
Requires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
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 ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Continuous learning and improving careRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement