Teonfa Ltd improved from Inadequate to Requires Improvement overall, exiting Special Measures, with Good ratings in Caring and Responsive domains following significant remediation since March 2023. However, continued breaches of Regulations 12 and 17 were identified due to incomplete risk management plans and ineffective audit processes failing to detect care planning gaps.
Concerns (4)
critical
Care planning
: “Identified risks to people did not always have corresponding risk management plans in place to support staff to reduce risks to people.”
criticalGovernance: “Care plan audits did not identify the issues we found at this inspection, for example, missing risk assessments.”
moderateRecord keeping: “Systems and processes to monitor the service were not always effective...the provider could not assure themselves records were accurate.”
moderateSafeguarding: “Risks in relation to moving and handling, catheter care and falls had not been fully explored. There was limited guidance to staff to keep people safe.”
Strengths
· Medicines were administered safely with clear guidance for staff, PRN protocols in place, and regular competency checks.
· Staff were recruited safely with robust pre-employment checks, DBS checks, and a specialist HR team.
· People felt safe and described staff as kind, caring and attentive to their needs.
· Staff received extended 5-day face-to-face induction training covering safeguarding, moving and positioning, and medicines.
· Provider was no longer in breach of regulations 9, 11, 13, 18 and 19 following improvements since last inspection.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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: Staff working with other agencies to provide consistent, effective, timely careGood
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: 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: Engaging and involving people using the service, the public and staffGood
Teonfa Ltd received an overall Inadequate rating following inspections in December 2022, with seven regulatory breaches identified spanning unsafe medicines management, absent risk assessments, unlawful restrictive practices, ineffective safeguarding, poor recruitment, widespread late visits, and a near-total failure of governance. The service was placed in special measures with warning notices served against both the registered manager and provider, representing a deterioration from the previous Requires Improvement rating.
Concerns (18)
criticalMedication management: “Staff told us they were crushing and administering medicines covertly without professional's agreement to determine if this was safe to do.”
criticalSafeguarding: “Staff had failed on two occasions to recognise safeguarding concerns related to fire risks, depriving a person of their rights and medicines.”
criticalCare planning: “During the inspection staff presented one person's care plan which contained information from another person's care plan.”
criticalStaff training: “The training programme set out meant staff had to cover 11 subjects within one day. This did not give sufficient time to support staff.”
criticalGovernance: “There was no quality assurance framework in place that would enable the provider to measure the quality of care accurately.”
criticalMissed or late visits: “Analysis of Teonfa's data for care visit times showed 37% of care visits were over 15 minutes late, 19% of which were over 45 minutes late.”
criticalConsent / capacity: “Staff did not understand the principles of the MCA or recognise restrictive practices. People had experienced unlawful restrictions.”
criticalRecord keeping: “Most people had missing care plans, missing risk assessments, inaccurate records and missing medicine records. Some people had no care plans or records at all.”
criticalLeadership: “The registered manager did not have the skills and knowledge to perform their role and have a clear oversight of the service.”
moderateStaff competency: “Staff did not have a good understanding of the conditions people were diagnosed with and how best to support them.”
moderateSupervision / appraisal: “Supervision notes contained identical wording across different staff and different supervisors. There was no evidence of competency assessments.”
moderateInfection control: “The registered manager and staff were not aware of the current government guidance in relation to the use of PPE and the prevention of spreading infections.”
moderateIncident learning: “Lessons learnt focused more on telling staff what they should or should not do but not enabling reflection on what went wrong.”
moderatePerson-centred care: “People were not all provided with culturally appropriate care. Some people felt their preferences and needs were not always understood by staff.”
moderateCultural competency: “Some people felt their preferences and needs were not always understood by staff where English was not their first language.”
moderateCommunication with families: “Most people and relatives told us they thought communication from office staff and management needed to be improved.”
moderateEnd-of-life care: “People's wishes for the support they would like in the event of becoming ill or at the end of their life had not always been discussed or recorded.”
minorComplaints handling: “Some people felt they could not go to the provider to complain due to concerns about the response and would instead speak to a social worker.”
Strengths
· Most people and relatives told us that they felt safe despite inspection findings.
· Some people felt most staff were friendly and caring.
· There was evidence of working with local authorities.
· The provider completed telephone surveys to gather people's views.
· A complaints policy and procedure was in place and most people knew how to complain.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and management; Using medicines safelyInadequate
safe: Preventing and controlling infectionInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Staffing and recruitmentInadequate
safe: Learning lessons when things go wrongInadequate
effective: Staff support: induction, training, skills and experienceInadequate
effective: Ensuring consent to care and treatment in line with law and guidanceInadequate
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Teonfa Ltd, a domiciliary care agency in Luton, received an overall rating of Requires Improvement following a focused inspection in November 2021, with breaches of Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) identified. Key failures included persistently late and missed care visits, unsafe medicines management, ineffective auditing that failed to detect widespread problems, and staff lacking knowledge of people's health conditions and safeguarding responsibilities.
Concerns (14)
criticalMissed or late visits: “Care visit times were inconsistent, often late by two hours or more and staff did not stay for the full length of the agreed time.”
criticalMedication management: “Staff were not aware of what the medicines were that they were administering and whether or not any of these had special instructions.”
criticalMedication management: “One person's medicine administration chart stated they had medicine for epilepsy and seizures, but their care plan did not mention anything about this.”
criticalGovernance: “One audit for a two-week period showed for one person that all visits had been met. However, daily diary records showed there were 44 late care visits and six missed ones.”
criticalSafeguarding: “Staff did not have a good understanding of how to keep people safe or how to identify and report various forms of abuse.”
moderateCare planning: “Risks were identified but measures to manage the risks were not clear and there was a lack of guidance for staff to follow.”
moderateStaff competency: “Staff did not understand the various conditions that people they supported had or how this impacted them. For example, diabetes and dementia.”
moderateIncident learning: “These had been shared amongst the staff team...However, these did not always translate to the care experience and people told us they had not seen improvements.”
moderateComplaints handling: “People told us they did not feel they were listened to and no action was taken to resolve their complaints.”
moderateConsent / capacity: “They also struggled to understand safeguarding or the principles of the Mental Capacity Act and how to ensure consent was sought.”
moderatePerson-centred care: “People's care could not be person centred in practice due to the inconsistency in care visit times.”
minorCommunication with families: “People felt communication from office staff could be better.”
minorInfection control: “People told us staff did not always wear PPE correctly in practice.”
minorCultural competency: “Some [staff] don't speak English. Some don't speak at all. It can be hard to explain to them what needs to be done.”
Strengths
· Some people said they felt safe as the staff were friendly.
· The registered manager completed checks on new staff to ensure they were suitable for the role.
· The provider was meeting shielding and social distancing rules and accessing testing for people and staff.
· The care planning system supported identifying personalised care including people's life history and likes and dislikes.
· The registered manager had employed a psychologist to work with staff on their well-being.
Quality-Statement breakdown (12)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Preventing and controlling infectionRequires improvement
well-led: 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 candour
Teonfa care services improved significantly from a previous 'Inadequate' rating and exited Special Measures, with most areas now rated 'Good'; however, persistent inconsistency in care visit times kept 'Safe' and 'Well-led' at 'Requires Improvement', as further time was needed to embed improvements sustainably.
Concerns (3)
moderateMissed or late visits: “Some people still experienced inconsistent care visit times... One relative said, 'Our only problem is that sometimes they have poor punctuality, and it's most difficult at weekends.'”
moderateGovernance: “A longer period was required to ensure that systems and processes had been embedded to enable staff to provide consistently safe, effective, compassionate, and good quality care.”
minorStaffing levels: “Some people were also concerned that constant changes in staff put them at risk of inconsistent care.”
Strengths
· Medicines now managed safely with timely MAR audits and staff competency assessments
· Robust staff recruitment processes including DBS checks and reference verification now in place
· Comprehensive training programme introduced covering MCA, dementia, diabetes and learning disabilities
· Staff supervision and appraisals now regular and well-regarded by staff
· Care plans personalised and detailed enough to support person-centred care
Quality-Statement breakdown (16)
safe: Staff deployment and visit timelinessRequires improvement
safe: Medication managementGood
safe: SafeguardingGood
safe: Recruitment processesGood
safe: Incident recording and learningGood
effective: Staff training and supervisionGood
effective: Mental Capacity Act compliance and consentGood
effective: Care planning and health needs identificationGood
Teonfa Care Services was rated Inadequate overall following a March 2017 inspection, with breaches of six regulations including safe care, staffing, consent, person-centred care, complaints and governance. The service was placed in special measures due to persistent failures in call reliability, medicines management, record keeping and leadership that had remained unresolved across multiple previous inspections.
Concerns (14)
criticalMissed or late visits: “Seventeen of them told us they had experienced missed calls since receiving care from the agency, whilst 24 raised concerns with persistent lateness.”
criticalMedication management: “Missed medication on the 21 January 2017 resulted in them having a seizure and being admitted to hospital.”
criticalStaffing levels: “The service was commissioned to deliver 812 hours of a support a week. This would have required each member of the care staff to work a 40 hour week with no allowance for holidays or sickness.”
criticalSafeguarding: “In January 2017 a safeguarding was raised because a service user was found 'wandering the streets' having not had their medicines which were critical for their cognition.”
criticalStaff training: “The service still did not provide training for staff to understand the Mental Capacity Act (2005).”
criticalConsent / capacity: “Five of the care plans we looked at had not been signed to indicate the person's consent to the care had been given.”
criticalCare planning: “The care plan within one person's records described them by the wrong name and gender. Therefore, we could not be certain that the information within the plan related to the person.”
criticalGovernance: “There was no straightforward method for the service to demonstrate to us the number of late, missed or 'clipped' calls and the action being taken in response to these.”
criticalRecord keeping: “One person had 47 visits unaccounted for between November and January, including seven entire days.”
moderateComplaints handling: “A response and outcome was not present in any of the complaints we looked at.”
moderateIncident learning: “We asked to see accident and incident forms to see how the service were responding to any incidents that occurred, however none had been logged since 2015.”
moderateStaff competency: “The service had accepted care packages for people with a variety of complex needs including learning disabilities, diabetes and epilepsy but did not provide any specialised training.”
moderateLeadership: “Following the first day of our inspection we were told that the new manager had resigned and that the provider would now apply to become the registered manager.”
moderatePerson-centred care: “Care plans included outcomes such as 'I would like to remain clean and presentable' which were generic in nature and often repeated across multiple care plans.”
Strengths
· Staff received regular supervision and appraisal and were subject to a full induction when they joined.
· Staff were positive about the culture of the provider and felt supported and listened to by management.
· Staff were able to contribute to the development of the service through team meetings.
· Most people and relatives reported that regular care staff were kind, compassionate and treated them with respect.
· Staff were aware of how to raise safeguarding issues and who to contact if they had concerns in relation to people's safety.
Quality-Statement breakdown (21)
safe: Missed, late and shortened care callsInadequate
safe: Medicines managementInadequate
safe: Staffing levels and deploymentInadequate
safe: Recruitment checksInadequate
safe: Risk assessments and incident recordingRequires improvement
safe: Safeguarding awarenessGood
effective: Staff training and competencyInadequate
effective: Mental Capacity Act training and applicationInadequate
Teonfa Care Services improved from 'Requires Improvement' to an overall 'Good' rating following its December 2018 inspection, with Safe, Effective, Caring and Responsive all rated Good. Well-led remained 'Requires Improvement' due to ongoing inconsistency in care visit times, unresolved complaints sustainability issues, and gaps in capturing end-of-life care preferences for all people using the service.
Concerns (5)
moderateMissed or late visits: “some people said there were still experiencing inconsistent care visit times which meant they were not always able to get on with their day”
moderateGovernance: “it was not clear why some people did not always tell the provider about these issues when they asked them for feedback”
moderateComplaints handling: “Other people said improvements made after they complained had not always been sustained. The provider needed to improve people's experiences of this.”
minorEnd-of-life care: “Only people requiring end of life care had this information in their care plans...most had not discussed how they would wanted to be supported at the end of their lives”
minorCommunication with families: “Some people also commented about some of the staff not being able to communicate clearly in English...this did not promote free conversations that would help them build relationships”
Strengths
· Effective risk assessments in place and systems to keep people safe from harm
· Safe staff recruitment processes with enough staff to support people safely
· Medicines managed safely with regular MAR audits and no concerns identified
· Evidence of learning from incidents and accidents with systems to prevent recurrence
· Staff received regular supervision and training to meet people's individual needs
Quality-Statement breakdown (16)
safe: Staffing levels and consistencyGood
safe: Risk assessments and safeguardingGood
safe: Medication managementGood
safe: Infection controlGood
safe: Incident learningGood
effective: Care planning and needs assessmentGood
effective: Staff training and supervisionGood
effective: Consent and Mental Capacity Act complianceGood
Teonfa Care Services was rated Requires Improvement overall following an unannounced inspection in March 2016, with breaches of Regulations 17 and 19 identified relating to inadequate MAR auditing and unsafe recruitment practices. Caring was the sole domain rated Good, supported by positive feedback from people and relatives, while systemic weaknesses in medicines governance, staff supervision, MCA training, and care plan personalisation drove the remaining ratings down.
Concerns (9)
criticalRecord keeping: “one person's medicine was signed for throughout September, but signed for infrequently and incorrectly in subsequent months”
criticalMedication management: “MAR charts were not always completed correctly...errors and omissions were not always identified or acted upon”
criticalGovernance: “Regulation 17 HSCA RA Regulations 2014 Good governance — Medicines Administration Records (MAR) were not always completed or audited correctly.”
criticalStaff competency: “Regulation 19 HSCA RA Regulations 2014 — References were not always validated and DBS checks were not always carried out appropriately.”
moderateSupervision / appraisal: “I've had one supervision since I joined. I haven't had a performance review yet but I'll have one soon.”
moderateConsent / capacity: “two members of staff were not certain of what the act was or how it applied to people using the service”
moderateCare planning: “care plans were adequate to capture people's individual needs, we found that often they were task-orientated and lacked personalisation”
moderateMissed or late visits: “The carers can arrive any time between 7:30 and 9am...rotas did not always include times for people to attend to calls”
moderateStaff training: “Staff did not always receive training in the mental capacity act and did not always understand how it applied in practice.”
Strengths
· People felt safe and staff demonstrated a kind and compassionate attitude, with relatives and professionals providing positive compliments about care quality.
· Risk assessments were in place for each person, with clear guidance for staff on managing individual risks including moving and handling.
· Staff received relevant training including care certificate induction, mandatory units, and specialised areas such as dementia awareness.
· Complaints were handled effectively, with the registered manager personally investigating issues and implementing corrective actions.
· Quality review calls sought feedback from people and relatives, with documented actions taken in response to negative feedback.
Quality-Statement breakdown (15)
safe: Recruitment and DBS checksRequires improvement
safe: Rota and call time managementRequires improvement
This focused inspection of Teonfa Care Services found ongoing breaches of Regulation 17 (good governance) and Regulation 18 (notifications), with people persistently receiving late or shortened care calls, rotas poorly managed, and three safeguarding incidents unreported to CQC. Some improvements were noted in medicines management and recruitment since the previous March 2016 inspection, but monitoring systems remained inadequate.
Concerns (8)
criticalMissed or late visits: “They're supposed to be here at 9am and this morning it was 9:25... On one occasion they turned up at 11:15 for a 9am call.”
criticalGovernance: “The failure to manage rotas and monitor visits in a way that meant that staff were being consistently deployed on time...was a breach of Regulation 17.”
criticalSafeguarding: “Since our last inspection there had been three safeguarding referrals, but none of these had been notified to us.”
criticalRecord keeping: “For one person there were no daily notes in their file since June 2015. This meant that the service had no way of monitoring visits to this person.”
moderateCare planning: “In the seven care plans we looked at we found that five of them were receiving calls at times that did not correspond with their agreed care plan.”
moderateComplaints handling: “Four people had made comments regarding the lateness of care staff, but no action was taken to address these concerns.”
moderateIncident learning: “Action was not being taken at the time when care staff failed to attend calls... the service could not take sufficiently prompt action to reduce the risk of recurrence.”
minorCommunication with families: “I've had no phone numbers or anything so I wouldn't know who to speak to if I wanted to.”
Strengths
· Recruitment procedures had improved; service now following own policy with competency-based interviews, DBS checks, two written references and identity verification for all staff.
· Medicines management had improved with MAR charts now completed correctly, no unexplained gaps, and monthly medicines audits introduced.
· Risk assessments were robust and detailed with individualised assessments and control measures in place for each person.
· Staff received safeguarding training during induction and understood how to recognise abuse and keep people safe.
· A compliance and quality lead was employed post-inspection to audit the service against Health and Social Care Act Regulations.
Inadequate
effective: Staff working with other agencies to provide consistent, effective, timely careRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires 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 careRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceRequires 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 needsGood
responsive: End of life care and supportRequires improvement
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInadequate
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Working in partnership with othersRequires improvement
Requires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Continuous learning and improving careRequires improvement
well-led: Working in partnership with othersRequires improvement
effective: Nutrition and hydration support
Good
caring: Kindness, respect and dignityGood
caring: Promoting independence and person-centred choicesGood
responsive: Person-centred care planning and involvementGood
responsive: Complaints handling and learningGood
well-led: Quality monitoring and governance systemsRequires improvement
well-led: Leadership, culture and staff engagementGood
well-led: Feedback and continuous improvementGood
effective: ConsentInadequate
effective: Meeting nutritional and healthcare needsRequires improvement
effective: Supervision and appraisalGood
caring: Kindness and compassion of regular staffGood
caring: Dignity and respectRequires improvement
caring: Consistency of care staffRequires improvement
responsive: Care planning and personalisationInadequate
responsive: Complaints handlingInadequate
responsive: Monitoring of visit timesInadequate
well-led: Governance and oversight of care deliveryInadequate
well-led: Record keeping and auditInadequate
well-led: Responsiveness of management to concernsInadequate
well-led: Staff support and team cultureGood
caring: Dignity, respect and person-centred support
Good
caring: Communication with people using the serviceGood
responsive: Person-centred care planning and reviewsGood
responsive: Complaints handlingGood
responsive: End of life care planningRequires improvement
well-led: Consistency of care visit times and people's experiencesRequires improvement
well-led: Quality monitoring and audit systemsGood
well-led: Engagement with people, staff and stakeholdersGood
caring: Kindness and compassion of staffGood
caring: Dignity and respectGood
responsive: Personalisation of care plansRequires improvement
responsive: Complaints handlingGood
well-led: MAR auditing and governanceRequires improvement