B24 Healthcare Solution Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to governance. Sufficient improvements were not found at this inspection and the provider remained in breach of this regulation.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The management team supported an open culture and had created a strong team ethos. Staff spoke positively about working at the service and felt well supported in their roles. One staff member told us, “We all support each other” and we saw examples of this.

Processes to involve people and staff in developing the culture included seeking people's feedback, through meetings and questionnaires on the quality of care and service provided. Where feedback showed improvements were needed, actions to make those improvements had been agreed.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Some improvements had been made since our last inspection. The provider had moved location to a larger office to accommodate more staff, and staff roles had been more clearly assigned. New appointments included a deputy manager who told us they had started in November 2025 and had identified areas for improvement. This included a ‘rationale’ recording system for missed and late care calls which they were working on implementing. Office staff understood the expectations of their role, responsibilities and tasks and felt supported by the management team. However, further improvement was needed in the provider ensuring all staff consistently had the skills, knowledge and experience to undertake tasks delegated to them to be fully effective in their roles.

The provider and management team were committed to delivering a good service, however, gaps in governance systems to monitor and improve the service meant effective oversight was not always in place. This limited the provider’s ability to learn lessons and fully drive improvements.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Office staff felt confident to raise any issues or concerns with the management team if needed and said they believed the provider would take action.

Care staff felt supported and able to speak up. One staff member told us, “I feel supported in my role, I am confident in the managers and they make sure we are okay.”

The provider also held regular team meetings, where staff had the opportunity to raise concerns and offer suggestions.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt included in decisions about the service and enjoyed working for the provider. Staff had received equality and diversity training. The provider’s policies promoted equality and diversity, and a diverse staff team had been recruited to support people supported by the service. One relative told us, “It is very good when the staff can speak my relative’s Asian language.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Whilst some improvements had been made since our last inspection on some checks on the quality and safety of the service, other areas were lacking and still required improvements.

Some staff handled people’s cash when, for example, they undertook grocery shopping for them. The provider had a Management and Handling of Service User’s Money policy; however, the provider was not following their own policy. There was no Financial Transaction Sheet in place for staff to complete, as the policy directed. Also, there were no checks taking place on any financial log and receipt copies despite the policy stating this analysis would happen. The provider confirmed this was not happening and told us they would take immediate action to implement their policy.

Following a local authority quality monitoring visit of the service during October and November 2025, the provider had told the local authority improvements would be made to MAR audits and 100% of MARs would be checked on a daily basis. This was not happening, and we found the December 2025 MAR audit had only recorded 3 MARs were reviewed. This meant the desired improvements in identifying any missed administration, missed signatures or medication errors were not always identified or addressed in a timely way.

The provider had not acted on feedback shared with them in October and November 2025, by the local authority, related to the safe administration of medicine via transdermal (skin) patches. We found no body maps, or other records, had been implemented by the provider to ensure the manufacturer’s guidance was followed.

The provider was aware their care call monitoring alert system had been turned off; the provider told us by the registered manager, for the past year. A missed care call was recorded during January 2025, but no action had been taken to reactive the system. When we asked why this was, they told us the system had generated “thousands of email alerts” each day, and this had been problematic. Whilst office staff looked at the care call system, they were also undertaking other work. This meant there was no effective oversight to ensure care calls took place at the agreed times or people were informed when staff were running late.

The provider had delegated ‘staff competency assessments’ to a staff member but had not ensured this staff member had the necessary skill or qualification to safely complete these. For example, the staff member was signing care staff off as competent using moving and handling equipment but had only completed the same level training as the care staff and not a ‘train the trainer’ qualification.

Systems and processes were in place but were not robust enough to identify the issues we found. For example, the care call ‘RAG’ (red, amber, green) rating was not visible on the call monitoring system or available centrally for quick access in an emergency. This resulted in staff having to manually go into each of the 84 people’s care records to find this information. The provider told us action would be taken to ensure a more effective overview would be created.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

People’s care records directed staff to work in partnership with healthcare professionals to ensure people had the best outcomes for their health and wellbeing. For example, staff worked with healthcare professionals liaising with the district nurse team when needed.

However, the provider had not always worked in fully effective partnership with commissioners from the local authority. Having received feedback from them, the provider had informed the local authority on how improvements would be made, but these had not been implemented in a timely way. For example, we saw the provider had not made the required improvements to ensure medicines were consistently administered safely.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider told us our last inspection feedback had been used to make improvements, and their aim was to continue to improve. On this inspection, we found some improvements had been made, such as personalised care plans rather than copied and pasted information which we had previously found.

Some further improvements were needed. The provider had not learned having an effective alert system on their care call monitoring was important for a safe service and good oversight.

During our last inspection we told the provider some information on their website was misleading to members of the public, informing them nurses were supplied to care and support people. At this inspection, we saw the same information was on the website despite the provider having told us it would be removed. The provider told us this had been an oversight and they would remove it.

Staff recorded incidents and accidents, and these were reviewed by the management team and some actions taken to prevent reoccurrence. However, improvement was needed to ensure actions were consistently recorded. For example, the provider told us staff were spoken with when issues needed to be addressed, but conversations were not always recorded. This meant lessons learnt could not be fully evidenced or referred back to.