Date of assessment: 3 – 14 October 2025. BBC Care Service Limited provides care and support to people living in their own homes, including people living with dementia, people with sensory impairment, and people with physical disabilities. The service is registered to provide care and support to people with a learning disability and 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. CQC onlyinspects 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 2 people at the time of our assessment, both of whom received personal care. The last inspection of the service was on 12 May 2023 when we rated the service Requires Improvement. The provider was in breach of legal regulations in relation to safeguarding, consent, and governance. Improvements were found at this assessment, and the provider was no longer in breach of these regulations. People received safe, well-planned care which was flexible to meet 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 had clearly defined roles and responsibilities, which ensured accountability for service delivery. The provider operated effective quality monitoring systems, including regular audits and spot checks on the care delivered by staff.
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BBC Care Service Limited, a small domiciliary care agency in Chertsey, improved from Inadequate to Requires Improvement overall, exiting Special Measures, but remained in breach of Regulations 11, 13 and 17 relating to consent/MCA, safeguarding and governance. While medicines management, recruitment, infection control and caring practice showed meaningful improvement, persistent weaknesses in safeguarding oversight, mental capacity assessment and governance audit effectiveness continued to place people at risk.
Concerns (10)
criticalSafeguarding: “On one occasion a potential safeguarding concern was not considered as such despite action being taken to mitigate the risks to the person at the time.”
criticalSafeguarding: “The provider's safeguarding policy was mistakenly naming the registered manager as external contact for safeguarding. This posed a risk of staff not knowing how to escalate concerns.”
criticalConsent / capacity: “The mental capacity assessments were still not always decision specific. Some capacity assessments did not address areas relevant to the person's support provided by staff.”
criticalGovernance: “The governance system and processes in the service were not always effective in recognising shortfalls and ensuring appropriate action was taken to remedy them.”
moderateConsent / capacity: “Where people had capacity to make their own decisions but could not sign consent forms, those were signed by their family. There was no record of their own consent being obtained.”
moderateGovernance: “The service improvement action plans were out of date and there were limited assurances around current improvement priorities for the service.”
moderateRecord keeping: “The staff attendance monitoring system was not always used effectively... records showed a consistent absence of staff on one person's care visits.”
moderateCare planning: “Not all people had relevant information around their interests, life stories or advanced care wishes included in their care plans despite this being addressed as an area of need.”
moderateIncident learning: “Incidents were analysed in isolation without looking at possible trends. It was also unclear how the provider's safeguarding policy was considered when assessing individual circumstances.”
minorEnd-of-life care: “Not all people had relevant information around their interests, life stories or advanced care wishes included in their care plans.”
Strengths
· Staff treated people with kindness, dignity and respect; relatives described staff as 'very helpful, patient and very friendly', 'good as gold' and 'very caring'.
· Medicines management improved significantly since last inspection; staff signed MAR records and were competency assessed, with no ongoing breach of Regulation 12.
· Safe recruitment practices now in place including DBS checks, employment history, references and application forms, resolving the previous Regulation 19 breach.
· No missed care visits since the last inspection; rosters allowed sufficient travel time and staff lateness was effectively managed.
· Staff received appropriate training including Care Certificate elements, practical competency assessments and condition-specific training such as dementia and MH awareness.
Quality-Statement breakdown (19)
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidance (MCA)Requires improvement
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standardsGood
effective: Supporting people to eat and drink; working with other agencies; accessing healthcareGood
caring: Ensuring people are well treated; respecting equality, diversity, privacy, dignity and independenceGood
caring: Supporting people to express their views and be involved in decisions about their careGood
responsive: Planning personalised care to ensure people have choice, control and meet their needs; end of life careRequires improvement
responsive: Meeting people's communication needsGood
responsive: Supporting people to maintain relationships and avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff clear about roles; quality performance, risks and regulatory requirements; continuous learningRequires improvement
well-led: Promoting a positive, person-centred, open and inclusive culture; engaging people and staffGood
well-led: Working in partnership; duty of candourGood
BBC Care Service Limited was rated Inadequate overall at its October 2022 inspection, remaining in special measures with continued regulatory breaches in safe care and treatment (Reg 12), good governance (Reg 17), consent and mental capacity (Reg 11), and fit and proper persons employed (Reg 19). While the consistent small staff team and an open management culture mitigated some immediate risks, systemic failures in medicines management, care plan quality, MCA compliance and recruitment oversight meant people remained at risk of avoidable harm.
Concerns (8)
criticalMedication management: “staff signed to state a medicine which was prescribed to be taken once a day was shown as administered twice a day. This was not identified in the medicines audit that month”
criticalGovernance: “The registered manager failed to identify they were still not working in line with safe recruitment practices and their own policy in this area.”
criticalCare planning: “People's care plans had significant discrepancies and lacked information around their individual risks, needs and preferences.”
criticalConsent / capacity: “there were no records of mental capacity assessments or best interests' decisions for these people. Despite additional training undertaken by the registered manager, they were not able to tell us how they implemented MCA”
criticalStaff competency: “for two staff the declared employment did not match their references and where staff worked in previous roles in care, their references were not always obtained.”
moderateRecord keeping: “one person's plan could not be located at all. Another person's plan included out of date information on the changes made to the time of their care visits.”
moderateStaff training: “Staff had not received any training relating to specific needs of the people they supported. For example, around dementia, communication, falls prevention, skin care or continence care.”
moderatePerson-centred care: “people's individual care and support plans did not always fully reflect those changes in practice. Care plans still lacked personalised detail on how people wanted to be supported”
Strengths
· Consistent staff team who knew people well mitigated immediate risks to people during visits.
· Registered manager closely monitored staff attendance and visit monitoring in real time, with no missed visits reported.
· Staff received supervisions, spot checks and unannounced observations of practice, and felt supported.
· Complaints handling improved; people were confident concerns would be listened to and responded to.
· Registered manager fostered an open, transparent and inclusive culture, engaging people, families and staff.
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongInadequate
safe: Using medicines safelyInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
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
BBC Care Service Limited was rated Inadequate overall and placed in special measures, with breaches of seven regulations including staffing, recruitment, medicines, consent, person-centred care, complaints and good governance. Late and missed visits, untrained staff, weak oversight and poor complaint handling put people at increased risk of harm, and Warning Notices were issued for governance and staffing failings.
Concerns (15)
criticalMissed or late visits: “There have been a couple of incidents that I've had to phone the office for as nobody showed up on Saturday and nobody called us.”
criticalStaffing levels: “The provider had failed to ensure there were always enough staff deployed to support people which put people at risk.”
criticalMedication management: “Not all staff supporting people with their medicines received training to do so and were competency checked.”
criticalStaff training: “Staff did not receive any specific training around supporting people living with learning disabilities and/or autism or supporting people living with dementia”
criticalGovernance: “The provider had failed to establish and operate effective governance systems which impacted on people's care.”
criticalLeadership: “I don't think the service is well-managed at all. I haven't got a clue who the manager is, the communication is very poor.”
criticalPerson-centred care: “The provider had failed to ensure the care provided was always appropriate and reflected people's preferences.”
criticalComplaints handling: “The provider had failed to operate an effective system to identify, receive, record, handle and respond to complaints.”
criticalConsent / capacity: “The provider had failed to act in line with the Mental Capacity Act 2005 and the related code of practice.”
moderateStaff competency: “Their competencies in respect of moving and handling or medicines administration were not checked at the point of the inspection.”
moderateCare planning: “people's care records were not always detailed enough and robust to ensure all their personal needs were considered by staff”
moderateSafeguarding: “they did not always follow the correct multiagency process and their own policy on reporting those to the local authority.”
moderateRecord keeping: “Staff did not always keep accurate record of the support they provided with medicines.”
moderateIncident learning: “Due to lack of robust records it was unclear how the registered manager analysed and investigated those events and concerns.”
minorCommunication with families: “I've only got one number, and I can't understand what they're saying to a degree.”
Strengths
· Staff received recent training in infection prevention and control and wore appropriate PPE
· Provider had appropriate plans and risk assessments around the COVID-19 pandemic
· Staff knew when to escalate concerns about people's health and worked with other professionals
· Registered manager was responsive to feedback and started making changes during/after inspection
· Some consistent staff were reported to be kind, friendly and respectful
Quality-Statement breakdown (20)
safe: Staffing and recruitmentInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Using medicines safelyInadequate
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Requires improvement
effective: Supporting people to eat and drink enough; staff working with other agencies; supporting people to live healthier livesGood
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
responsive: Planning personalised care to ensure people have choice and control; end of life care and supportRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
responsive: Meeting people's communication needsRequires improvement
responsive: Supporting people to develop and maintain relationships; support to follow interests and activitiesGood
well-led: Managers and staff being clear about their roles; understanding quality performance, risks and regulatory requirements; continuous learningInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Working in partnership with others; duty of candourGood
Requires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies; supporting people to access healthcare servicesNot rated
caring: Ensuring people are well treated and supported; respecting equality, dignity and independenceRequires 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
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships and follow interestsNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careInadequate
well-led: Promoting a positive culture; engaging people and staff; duty of candourInadequate
well-led: Working in partnership with othersNot rated