Logic Care Solutions

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the management of people’s medicines and deployment and training of staff.

This service scored 44 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. We could not be assured people benefitted from a service that learned lessons from incident and accidents and put measures in place to reduce the likelihood of these reoccurring. Accidents and incidents had not always been reviewed and dealt with by the management team in a timely manner. Staff told us they completed accidents and incident forms when people had fallen. The registered manager told us a number of times there had been no accidents and falls. When we challenged this based on examples given by staff the registered manager told us there had been falls. They then explained they had taken action to create a falls monitoring form to record falls for use when staff witnessed falls, but expected a different procedure for unwitnessed falls. They explained they would consider how to mitigate reoccurrence. The registered manager acknowledged that not all incidents raised by staff had been logged, and explained this was an issue they were looking into. The registered manager told us they were going to ensure incident forms were logged and actions and lessons learnt would be incorporated into the process.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The provider carried out assessments of people’s needs prior to their package of care and support starting. This enabled them to meet people in their own homes. Staff told us care plans and risk assessments were in place when they carried out their care and support visits. However, the structure of these assessments varied and not all relevant information had been recorded within the assessment to create detailed care plans for staff to follow. For example, important information about allergies, religion and assessments of the environments were missing. This meant staff did not have all the information they needed to understand people’s care and support needs, wishes and preferences. We received mixed feedback from staff about care plans and assessments. Comments included, “A female client needs reassessing, and this has been raised over the last year”; “No care plans are updated, [person] has a care plan that states she must have someone sit whilst she eats but she is independent” and “I always check care plans and risk assessments for new clients and it gives me information on what to expect.” People and relatives told us their needs were assessed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People were safe and were protected from harm. Safeguarding and whistleblowing policies were in place and were accessible to staff. Staff were aware of the safeguarding policy. A member of staff said, “Safeguarding adults at risk this was face to face (training) and I have also done the theory. I have not had to do one but have raised concerns with my manager who has taken this forward.” Another staff member said, “I have done safeguarding. I reported to the manager as I had a client who was being financially abused by a relative. I reported it and it was sorted. I can speak to CQC if I was not listened to.” People and their relatives told us they felt safe.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people were not always identified and risk assessments lacked enough detailed information for staff to know how to keep people safe. For example, we found some evidence in people’s daily notes which showed risk assessments were not being followed. Comments included, “People’s needs change especially when they have gone to hospital and come back. If they are new, we are given guidelines on what to do, we report things and changes” and “Care plans are outdated and do not reflect their current needs.” There were no risk assessments in place for staff transporting people into the community in their own vehicles. People who were at risk of choking had risk assessments in place which listed staff were to cut food into small pieces, but the risk assessment did not provide information about what size those pieces should be and did not refer to people’s speech and language therapy assessments or IDDSI (The International Dysphagia Diet Standardisation Initiative) guidance. This put people at risk of harm.

There were anticoagulant risk assessments in place for some people who were prescribed this medicine. Not everyone prescribed anticoagulants had a risk assessment in place to detail safe ways of working for staff. The anticoagulant risk assessments that were in place did not highlight risks to people if they fell and what action staff should take. Diabetes risk assessments were not in place. We reported our concerns to the registered manager during the assessment process, and they arranged for amendments to be made to make risk assessments clearer for staff.

We received mixed feedback from staff in relation to the management of risks. Some staff we spoke with did not know the signs and symptoms of low or high blood sugars for people diagnosed with diabetes.

Despite the evidence above, people and relatives told us they and their loved ones were safe and staff knew them well.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.Risks relating to the environments staff were working in had not been fully assessed. For example, risks relating to access, egress, flooring, lighting, location of emergency shut offs for gas, electric and water. We discussed this with the registered manager. They advised they would review the risk assessments and add additional information to ensure staff had all the information they needed to keep themselves and people safe. During the assessment process some of these were put in place, however they contained conflicting information.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not work together well to provide safe care that met people’s individual needs. They made sure staff received effective support, supervision and development. Whilst the staffing rota showed staff had time between care calls, staff reported that the time was not always adequate. Staff were starting their care calls earlier than scheduled to get ahead. Staff told us they had not always been given adequate time on their rota to travel between care calls which meant they were late for care visits, or they started very early in the morning to get ahead. Comments included, “Travel time is a dicey thing. We don’t get enough travel time; it’s not totally a management fault. Most service users want the time, and we work around it. There are lots of roadworks currently. We call and say we are running late. Sometimes we leave early in the morning to start calls early. We do not cut calls short”; “We have enough time to travel, if we have an issue such as a blocked road, we call the manager. We don’t keep clients waiting and don’t cut short times” and “We have travel time, and we start early to get a head start and to be able to get through all the calls. Travel time isn’t all that much.”

We found evidence in people’s daily records that they were having shortened calls. Some electronic call monitoring records showed some people were having very short care visits. Several people had a 30-minute care call scheduled and records showed a person had a 3 minute visit on 21 February 2025. Another person was getting approximately 10 minutes of their 30 minutes provided each day in May 2025. Some people were having their care visits very early and not at a time that suited them. This meant staff were leaving medicines out for them and doing tasks whilst the person was sleeping. The person’s daily records confirmed this.

People and relatives gave us mixed views about their experience of staff providing care and support at the right time for them. Comments included, “If they come at 06.30, I am asleep, so they leave me in bed, and I have to sort my own pads out. If I wake up at 08.30 to 09.00, they give me a strip wash, but I have to ask them to. They give me breakfast. Most days they leave me in bed. I have rung the manager when they came one and a half hours late”; “She (staff member) arrives on time and stays the full duration”; “The staff don’t always stay for the duration of their visit. If they complete all the tasks they are meant to, and I am happy then I don’t make a fuss of it" and “They have always come around the time they are supposed to be here and have not missed one out.”

Staff did not always have the right training to meet people’s needs. No staff had attended diabetes training despite supporting people with diabetes. Staff were allocated this training during the inspection after we raised it with the registered manager. Staff did not have a good understanding of diabetes despite having just completed the training. Only 2 out of 21 staff had completed dysphagia training despite staff supporting people who had difficulty swallowing and receiving food and fluids which were tailored to their assessed needs. Spot checks and supervisions were taking place. Staff told us they received induction, support, supervision and training. A staff member said, ‘[Registered manager] does spot checks, she did one on Sunday unannounced. Supervision is every 3 to 4 months. I have had 2 this year already.”

Before and after we inspected the service, we received information of concern about sponsorship licences for staff. We reported these to the UK Visa and Immigration service. We examined 3 staff files, and all of the required checks had been carried out and documents were all in date. In files we saw copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The provider had an up-to-date infection prevention and control (IPC) policy. Staff had completed IPC training. Staff told us they had access to personal protective equipment (PPE) to keep themselves and people safe. A staff member said, “I have PPE in my car, and we can go to the office to pick up more, such as shoe covers, aprons and sanitiser.” The provider carried out spot checks of staff practice which included checks to make sure staff were using PPE appropriately.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. Medicines were not well managed. People were not always having their medicines as prescribed which had the potential to cause them harm. Medicines administration records (MAR) showed gaps in recording and daily records did not evidence medicines had been administered as prescribed. A person had not had their Vitamin D medicine for more than 1 month. Staff had been recording the medicine as not given or out of stock. The call monitoring system had not flagged up to the management team that the person had not received medicines as prescribed. We reported this to the registered manager who took action with the person’s relative to amend arrangements for who would order and collect medicines. A person’s MAR showed that staff had been signing the medicines to show they had given them. However, staff had not administered the medicines as they had left them in a pot for the person to take when they awoke. This meant the provider could not be assured the person had received medicines as prescribed. The person told us that staff arrived too early in the day to provide care and support. They told us, “They give me medication but if I’m asleep they leave them by my bed.”

Staff told us they received training and competency checks in relation to medicines. Comments included, “I give prescription medicines and am competency checked and trained. I don’t give anything outside the prescription, some medicine is needed PRN (as and when required medicines)” and “I have done medicines training and have done medicines competency, we do it regularly.”