During an assessment under our new approach
We carried out a comprehensive inspection of Pacific Care Services Limited (Isle of Wight) on 2 and 10 December 2025. This was a risk-based inspection prompted by the length of time since the previous inspection in March 2022 and concerns received about staff skills, medicines management, and governance. The service provides personal care to people living in their own homes, including older adults, people with physical disabilities, mental health needs, and some people with a learning disability or autism.
An inspection has been undertaken of a service that is used by autistic people or people with a learning disability but is not registered as a specialist service. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found the service was meeting the principles of ‘Right support, right care, right culture’. The service was supporting people with a learning disability without having the correct service user band in place. The nominated individual told us applications to update registration had now been submitted.
Risk assessments were not consistently in place for specific health needs such as diabetes, epilepsy, catheter care, and blood-thinning medicine. Medicines management required improvement: some staff administering medicines had not had competency assessments, and there were inconsistencies between medicine records and emergency “grab and go” sheets. We found gaps in recruitment checks, including incomplete employment histories and missing information from previous roles involving vulnerable people. Safeguarding procedures were not always followed: an allegation raised by a family member was investigated internally without referral to the local authority or notification to us. This placed people at risk of harm.
Governance systems were not robust. Audits had not identified the issues we found, and some had not been completed as planned. Feedback processes such as surveys had not been carried out, and there was limited evidence of learning from complaints or incidents. The provider had not notified us of all significant events.
People and staff raised concerns about continuity of care and scheduling. Many people reported having different carers rather than regular staff, and some said visit times were variable, meaning they could not have a regular daily routine such as mealtimes. Staff told us they sometimes had back-to-back calls with insufficient travel time, which could lead to rushed care or delays in attending subsequent people. Out-of-hours support was described as less effective, with calls diverted to a mainland office where responses were sometimes abrupt or unhelpful.
There were examples of good practice. Care plans contained detailed, person-centred information, and staff were flexible in responding to changing needs, such as hospital discharges or requests for extra support. Staff confirmed they had access to Personal Protective Equipment [PPE] and infection control training, and people told us care staff always wore disposable gloves and aprons where required. Training was up to date, and new staff undertook shadow shifts before working alone.
External professionals were mostly positive, describing the office team as approachable and responsive, and 1 said, “I would happily have Pacific oversee my family’s care package if it was ever needed”. Staff were described as kind and respectful, and most people said care staff encouraged independence and treated them with dignity.
The provider was in breach of the legal regulations relating to risk assessment, medicines management and good governance.
Any enforcement action will be published once the factual accuracy process and any appeals have concluded. We will request an action plan from the provider to show how they will address the breaches identified.