Date of Assessment: 18 February to 18 March 2026. This was a comprehensive assessment of all 5 key questions triggered by our ongoing monitoring of the service. The service is a care at home service providing support to adults of all ages living in their own homes. At the time of the inspection 10 people were using the service. CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. There was a positive learning culture, where the provider was proactive in seeking feedback and implementing learning to make improvements. People and their relatives knew how to give feedback and were confident the provider took it seriously and acted on it. People were protected and kept safe from abuse. Staff were happy to raise any safety concerns and felt they would be dealt with properly. There were enough staff in place. Some improvement was needed to staff recruitment process. People were consulted around how they wished their care to be carried out. Staff understood and managed risks related to people’s care, however some risk records needed to be more detailed. Safe systems were in place to ensure medicines were administered appropriately where required by competent staff. Staff worked with stakeholders involved in people’s care to promote the best outcomes and safe transitions when people moved between services. The provider made sure staff received training including condition specific training to maintain high-quality care. Staff cared for people with dignity and respect and promoted their independence. People were treated with kindness and compassion and had a good level of consistency in care staff. Leaders were visible and supportive, helping staff develop in their roles. The registered manager was capable and undertaking relevant further qualifications. Staff felt able to give feedback and were treated equally. Governance was in place and mostly effective, but the provider had not picked up the issues we found with documentation for recruitment, risk, consent and care plans. The provider worked during the assessment to rectify these processes and put in place appropriate oversight going forward. The provider worked with stakeholders in the local community to deliver the best possible care and were receptive to new ideas.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-9115571469.
First inspection of this newly registered domiciliary care agency identified breaches of Regulations 17, 18 and 19, with unsafe recruitment, inadequate staff training/competency systems, missing audits, and incomplete care records. People nonetheless reported caring, dignified and responsive support from the registered manager and staff.
Concerns (13)
criticalStaff training: “There was little evidence that staff had been provided with all the appropriate training for their roles.”
criticalStaff competency: “There was not a robust effective system in place to ensure that the provider employed people who were suitably qualified, competent and experienced.”
criticalGovernance: “there were no audits, and incidents and accidents had not been recorded and reported. Some records were incomplete”
criticalRecord keeping: “failure to maintain accurate records was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
moderateCare planning: “Care and support plans were not always accurate, personalised and did not reflect the needs of the person. The care plans we checked were incomplete”
moderateSafeguarding: “The service had identified potential abuse of one of the service users and reported this to the local authority, however they had failed to also report this to CQC.”
moderateIncident learning: “There was no process for learning from accidents/incidents, safeguarding and complaints.”
moderateMedication management: “there was no evidence that staff training in safe administration of medicines had been provided or competency checked. This presents a risk that people may receive their medication incorrectly.”
moderateSupervision / appraisal: “There was no evidence of formal staff supervisions, although staff felt supported by the registered manager as they listened to them.”
moderateComplaints handling: “We did not see evidence of a complaints policy as part of this inspection. The registered manager said that they were looking to put in a system to monitor the handling of complaints.”
moderateConsent / capacity: “there was no evidence of consent to care being documented in people's care plans. Staff we spoke to had a mixed understanding of the MCA.”
moderateLeadership: “the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
minorEnd-of-life care: “The provider was going to but had not yet included training in these areas for staff.”
Strengths
· People felt treated with dignity, respect and privacy during personal care
· Provider was responsive to changes in care needs and flexible with timings
· Infection prevention and control policy was up to date and PPE used effectively
· Registered manager made timely referrals to health and social care professionals
· Open and transparent partnership working with other agencies and healthcare professionals
Quality-Statement breakdown (24)
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Learning lessons when things go wrongNot rated
safe: Preventing and controlling infectionNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards
Not rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated