Mobile Care Services 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 good. At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to governance at the service.

This service scored 50 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider had acquired Mobile Care Services Limited during the early part of 2025. Staff told us many changes had since taken place, and these included a revision of policies, a new IT system and staffing changes. Staff shared they did not consistently feel a part of those changes or that a vision for the future had been shared with them. This contributed to inconsistent practice and low staff confidence in how changes were being managed.

Following the acquisition of Mobile Care Services Limited, the provider's operations manager had held engagement meetings for staff and had also made weekly visits to the office for six months to give staff the opportunity to discuss any concerns or organisational changes. Despite this, office and care staff did not feel the provider had developed effective or sufficient opportunities for them to engage or develop a culture based on openness and stability.Some staff shared concerns with us about workforce security and their fears for how future changes would be managed.

However, office and care staff across departments talked positively about the manager and senior teams within the service despite changes and re-structures across the organisation.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. 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 systems and processes in the office were new and not yet embedded into practice. Not all office or senior staff knew how to use them to ensure effective oversight or delivery of care. For example, in finding information about which people’s care calls were high priority. Numerous staff spoke about the lack of training they had received, with them telling us, “It was 1.5 hours on teams for the new IT training, it has not been enough.” When we asked staff to locate information to share with us, often they told us they did not know where to find it. This included what care hours had been delivered to individual people.

Some staff told us they did not feel valued following the change in provider. A few staff told us they feared the future, in moving elsewhere, having been settled for many years at the service.

This meant the provider had not always handled changes as well as might have been. This lack of capability contributed to gaps in oversight and inconsistent monitoring.

People did not always feel they could speak up and that their voice would be heard.

Some staff told us that recent changes in the service had left them feeling frustrated and that their views and feelings had not been listened to by the new provider. For example, some staff said concerns were not addressed and training issues were ignored. They felt, in certain circumstances, communication had been poor and they did not feel valued.

Staff felt confident to raise concerns about people and their care, to the manager and team leaders, and felt confident these concerns would be actioned and taken seriously. Staff told us they felt comfortable highlighting their own errors when things had gone wrong, without fear of blame.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The staff team had experienced numerous changes over the past 12 months. One team leader told us, “It's been a year of learning. We are still learning the new system. It's far from finished.” This staff member added, “The workload is not currently manageable.” This sentiment was shared by other office-based staff who spoke with us. Some team leaders told us that the provider did not appreciate the length of time it took them to complete some tasks and that a lack of support and training had not enabled them to do their job well.

Not all staff felt there was a fair culture between care teams. Some staff told us the provider had guaranteed contracted hours for some care staff but not others, who had been employed many years, and this had created some uncertainty within the workforce. This contributed to a workplace culture where staff did not feel equally valued. In response to being made aware about staff's feelings, the operations manager told us they were not aware of any instance where a member of staff had formally requested contracted hours and was refused without legitimate operational reason. The operations manager also told us that contracted hours were introduced as a workforce improvement, following their acquisition of Mobile Care Services Limited, and were not offered selectively or unfairly.

Some staff told us they had not received regular supervision meetings and therefore had not been given opportunities to discuss their concerns or identify areas for development.

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.

Although systems and processes were in place to assess the quality and safety of the service, these were not always effective. Where areas for improvement had been identified either by the Local Authority or through the provider’s own checks, improvements were not implemented as required in a timely way to monitor the quality and safety of the service.

We identified further areas in need of improvement which the provider’s own systems and processes had not identified. For example, the provider’s checks had not identified body maps were not in place to ensure the manufacturer’s guidance was consistently followed when administering transdermal patch medicines to people. The provider’s care plan checks had not ensured robust information was consistently available to staff to ensure best practice in care delivery. For example, we found some recognised tools to assess people’s care needs and risks had not been fully completed.

Where medication errors had occurred, these had been investigated by the manager. However, where an investigation outcome action had been to ‘refresh guidance on medication administration’ for staff members, this had not happened and no furthercompetency assessment had been undertaken. We found examples of 4 staff members who continued to administer medicines to people and the manager agreed further training and a competency check should have taken place. This posed potential risks of avoidable harm to people.

As a result, the provider’s systems and processes were not fully effective in improving the quality and safety of the service. The governance shortfalls we identified resulted in a breach of the regulation.

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.

The provider and manager were working with one Local Authority to make improvements to the service. However, whilst the operations manager’s quality monitoring reports identified areas in need of improvement, there was no action plan to show when, how and by who would ensure these improvements would be made in a timely way.

The operations manager and manager told us they were committed to addressing the shortfalls but there was much to be achieved. This meant in the meantime, people did not always receive the quality of service desired by the provider.

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.

Further work was required to ensure learning took place from concerns, complaints and incidents and, for example, for staff re-training and assessments to take place when needed.

Improvements were also required to ensure staff consistently had the information they needed to ensure care and support was delivered in line with best practices.

Both the provider and manager had a desire to improve the service and learn from incidents, audits, and feedback. However, they had faced some challenges during recent service changes which they felt had delayed them in driving forward some improvements. The manager told us, “We know we have a lot to do, it has been extra challenging as we did not know clear dates from 1 Local Authority when some changes would take place for some people’s packages of care.”