Date of assessment: 6 May to 23 May 2025. Delore Care Surrey provides support to people living in their own homes, including people living with dementia. 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 service supported 35 older people at the time of our assessment, all of whom received personal care. The service is registered to provide care and support to people with a learning disability or autistic people. No autistic people or people who had a learning disability were using the service at the time of the assessment. However, we assessed the service under Right Support, Right Care, Right Culture, as it is registered to provide care and support to this population group. The assessment was carried out by an inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. We met with the provider via Microsoft Teams to hear how they managed the service and ensured people received safe and effective care. We reviewed documentation including care records for 4 people, and records related to staff recruitment, training and supervision, medicines management, and quality monitoring and governance. We spoke with 2 people who used the service and 10 of their relatives to hear their views about the service. We received feedback from 2 professionals who had worked with the service and 11 staff. We reviewed the Provider Information Return (PIR) submitted in March 2025. This is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We carried out this assessment as we had received information of concern about some staff not staying the full length of scheduled visits, and the attitude and approach of some staff. We did not find evidence to support these concerns. Our findings about callcompletion and the attitude and approach of staff are detailed in the main body of this report. The last inspection was on 20 April 2023 when we rated the service Requires improvement. The provider was previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation. People received safe, well-planned care that was tailored to their individual needs. Any risks involved in people’s care were assessed and mitigated. Staff received safeguarding training and understood their roles in protecting people from the risk of abuse or avoidable harm. The provider worked with other relevant agencies to investigate and take action if safeguarding concerns were raised. Staff were recruited safely and had access to the induction, training and support they needed to carry out their roles. The management team and staff understood the importance of effective information-sharing amongst each other and with other relevant professionals. The provider had established effective working relationships with commissioners and other stakeholders. The management team had clearly defined roles and responsibilities, which ensured accountability for key areas of service delivery. The provider’s quality monitoring and governance systems were effective in identifying risks or areas where improvements were needed.
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Fairolive received an overall rating of Requires Improvement at this April 2023 inspection, remaining in breach of Regulation 17 (Good Governance) due to persistent issues with missed and late care calls, poor communication with people using the service, and a failure to ensure most staff received learning disability training. Improvements were noted in staffing stability, medicines management, care planning and person-centred care, with Effective, Caring and Responsive all rated Good.
Concerns (6)
criticalGovernance: “Management had not sufficiently improved their governance processes to ensure they provided a consistently good quality service as we received comments from people around poor time keeping and late and missed calls.”
moderateMissed or late visits: “"I never know when the carers are to visit or how long they should be staying" and, "I'm not sure why I only get 15-minute visits when I am paying for 30 minutes."”
moderateStaff training: “20 of the 27 staff had not received learning disability training despite the agency being registered to provide care to people in this service user band.”
moderateCommunication with families: “The service did not have good communication systems in place. "Today we were called to tell us the carer was running late. This is the first time that anyone has done that."”
moderateRecord keeping: “There was a lack of understanding of the requirements of registration. We discovered the agency was providing care to people living in Sussex, although we had not been told this prior to our inspection.”
minorInfection control: “"No masks or aprons, but most wear gloves" and, "Not all carers wear aprons or gloves"”
Strengths
· People felt safe with staff and staff could recognise potential signs of abuse and knew who to report them to.
· Staff were recruited through a robust process including full employment history, references, right to work checks and DBS checks.
· Electronic medicines administration system enabled office staff to review records for missed medicines; only trained and competency-assessed staff administered medicines.
· Care plans were live electronic documents, regularly reviewed, and relatives could access them with consent.
· Staff worked effectively with external health agencies including GPs and district nurses to support people's health needs.
Quality-Statement breakdown (21)
safe: Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
Fairolive, a domiciliary care agency in Egham, remained rated Requires Improvement following a focused inspection in February 2022, with continued breach of Regulation 17 (Good Governance) due to inconsistent care planning, shortened care calls, and inadequate medicine and audit oversight. Improvements were noted in safeguarding, infection control, complaints handling, and staff recruitment since the previous inspection.
Concerns (7)
criticalGovernance: “The lack of good governance of the service was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
moderateMedication management: “staff were not recording the dosage correctly on one person's medicine record as they had been writing ½ tablet in the book, rather than 1½ tablets”
moderateCare planning: “there was a lack of detail in relation to one person's diabetes and a second person who was at risk of neglect. However, daily records showed staff knew people well”
moderateMissed or late visits: “Timing of calls is an issue. Sometimes they can be here before nine and some days it's way after nine”
moderatePerson-centred care: “one person was recorded in their care plan as being at risk of social isolation…care calls were regularly recorded as 15 or 20 minutes instead of half an hour”
moderateRecord keeping: “There continued to be a lack of effective systems and overall governance of the service…a disparity between care plans, with some containing good information and others not.”
minorIncident learning: “one person was found unresponsive when the carer arrived. There was little detail on the incident form as to what action the carer took”
Strengths
· Safeguarding reporting processes had been strengthened and staff knew how and when to raise a concern.
· No missed calls were identified; monitoring of care calls was more robust.
· Staff were recruited through a robust process including DBS checks and conduct checks.
· Infection control improved with the registered manager introducing PPE monitoring into quality assurance calls.
· Complaints system improved with a robust complaints log and responsive action taken.
Quality-Statement breakdown (12)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and management; Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentGood
safe: Using medicines safely; Learning lessons when things go wrongRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
Fairolive, a domiciliary care agency serving 75 people, was rated Requires Improvement overall (Well-Led: Inadequate) at its first CQC inspection in February 2021, with breaches of Regulations 12, 13, 16, and 17 and a Warning Notice issued for governance failures. Widespread concerns were found including missed and short visits, absent care plans for at least 37 people, poor medication record-keeping, inadequate PPE use, no complaints log, and insufficient management oversight to detect or address these shortfalls.
Concerns (12)
criticalMissed or late visits: “They don't stay the allotted time of 30 minutes – they are there approximately ten minutes. A relative told us, "We were lucky if we got four or five minutes."”
criticalSafeguarding: “The lack of systems and processes to effectively prevent abuse of service users was a breach of Regulation 13 of the Health and Social Care Act 2008.”
criticalInfection control: “The guy who came today didn't have any gloves on him and I didn't have any in the home. Some are wearing masks, and some are not wearing them.”
criticalMedication management: “We found handwritten medicine details for people which lacked prescription information. The MARs we looked at only had people's first names, no GP information, no record of allergies.”
criticalCare planning: “We noted a document stating 37 people did not have a support plan. We found commencement dates of June 2019, November 2019 June 2020 and December 2020 amongst those without a support plan.”
criticalGovernance: “The lack of monitoring of the service to ensure good outcomes for people, robust auditing, contemporaneous record-keeping and general governance was a breach of Regulation 17.”
criticalComplaints handling: “The agency did not hold a complaints log giving information on complaints received, action taken and outcome. People told us they were unsure on who they could report complaints or concerns to.”
moderateRecord keeping: “On one person's log sheets staff had repeatedly not filled in leaving time. In another's, staff had not stayed the length of time in line with the person's support plan.”
moderatePerson-centred care: “There was a lack of person-centred information in the support plans we reviewed. I just feel like a dot on the map.”
moderateIncident learning: “We did not see any evidence of what had been done about the delay in producing support plans, missed calls for people or staff not staying the full length of time at care calls.”
moderateLeadership: “I don't think [registered manager] understands her responsibility and how to take action. She seems to just fob us off with a response that makes no sense.”
moderateStaff competency: “Despite staff receiving the opportunity to take training in areas such as infection control and safeguarding, we identified shortfalls in their practices.”
Strengths
· Staff were recruited safely with appropriate DBS checks, right-to-work verification, and full employment history checks.
· Staff received wide-ranging training during induction including moving and handling, safeguarding, MCA, and medicines.
· Staff received supervision and appraisals and consistently reported feeling supported and valued by management.
· The agency worked with external agencies including the tissue viability team, hospital discharge team, and Skills for Care.
· Staff demonstrated compassionate attitudes, with examples of person-centred interactions reported by some people.
Quality-Statement breakdown (20)
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitment; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced diet
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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 ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
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 staffGood
well-led: Continuous learning and improving careGood
well-led: Working in partnership with othersGood
Good
well-led: Promoting a positive culture; Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
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 staffRequires improvement
well-led: Working in partnership with others; Continuous learning and improving careGood
Good
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
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 careRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInadequate
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Continuous learning and improving careRequires improvement