Gain Healthcare Ltd

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. At our last assessment we rated this key question good. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, the ways people’s medicines were managed safely, safeguarding, governance at the service and staff training.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not a consistently proactive or positive culture of safety within the service. Concerns about safety were not always investigated, and staff did not consistently document or report safety‑related events. This meant the provider did not always identify learning or use incidents to improve practice.

Incident logs did not include all known incidents, which significantly limited the provider’s ability to monitor safety effectively or identify themes and trends. This meant opportunities to reduce the risk of reoccurrence and improve people’s safety were missed. Where incidents had been recorded, follow up actions were not always clear, completed or reviewed, and learning was not embedded into practice.

Staff we spoke with, told us they were often left to work independently without regular checks or debriefs following incidents. We found no evidence of lessons learnedbeing implemented into people care. For example, where an incident form and team meeting referenced strategies intended to support the person, these actions had notbeen incorporated into the individual’s care plan, limiting the ability for staff to apply these approaches consistently.

Relatives told us that their feedback was not always acted upon. They raised concerns staff sometimes arrived without wearing name badges and they were not informed in advance which staff would be attending their home. This was particularly important due to their family member’s individual needs. Relatives felt their concerns were not responded to appropriately, and opportunities to improve practice were missed.

The provider did not always work effectively with people or healthcare partners to establish and maintain safe systems of care. They did not consistently manage or monitor people’s safety, and arrangements to ensure continuity of care.

There were limited systems in place to monitor people’s safety. This meant the provider was not always able to identify risks or take timely action to reduce them.

Initial referrals to the service contained details important to the person which had not been included within their care planning.

We found that the medicines listed in the person’s care planning were not relevant to the individual. This posed a risk when the person moved between services, for example if they were required to be admitted to hospital, as inaccurate or irrelevant medicines information could lead to unsafe treatment or errors.

The provider failed to work effectively with people and relevant healthcare partners to understand what being safe meant to them or how to achieve this. They did not consistently prioritise people’s right to live safely and free from abuse, discrimination, avoidable harm or neglect. Concerns about people’s safety were not always shared appropriately or acted upon in a timely way, which placed people at risk of harm.

The provider told us they raised safeguarding concerns for people they supported. During the inspection, we were made aware of an incident where a person was allegedly harmed by a member of staff that had not been recorded in the person’s daily care records or the associated incident form. The provider had notified CQC, however the notification contained inaccurate information. The incident had not been referred to the safeguarding authority, and no investigation has been completed by the service.

This demonstrated a failure in safeguarding processes and raised significant concerns about the accuracy and reliability of information being shared with external agencies. When we requested body maps or injury documentation to corroborate the concerns, the provider was unable to provide this evidence. As a result, we were not assured that injuries or concerns had been appropriately assessed, recorded or acted upon.

Where people were supported using restrictive practices, there was a lack of clear guidance within the care plan. Risk assessments, justification and documented decision making processes were not in place to demonstrate that restrictive interventions were lawful, necessary and proportionate. There was no evidence to confirm that staff had received relevant training or competency assessments to safely use restrictive practices. This represented a serious safeguarding risk and increased the likelihood that harm could occur without appropriate identification, reporting or escalation.

The provider’s safeguarding policy stated the services safeguarding log should include full details of concerns raised, decisions made following investigation, actions taken, learning identified and recommendations such as care plan updates. However, the safeguarding log was incomplete, lacked critical information and did not include safeguarding concerns raised for 2026. This meant there was no effective oversight, audit trail, assurance that safeguarding concerns were being investigated appropriately or that learning was being used to improve people’s safety.

The provider’s failure to identify, record, report, investigate and learn from safeguarding concerns represented a significant and ongoing risk to people’s safety. Systems were not effective, staff were not properly supported or guided, and leaders did not demonstrate sufficient oversight or understanding of their safeguarding responsibilities. These failings placed people at risk of avoidable harm.

The provider did not work effectively with people to understand, assess or manage risks to their safety. Staff did not consistently deliver care that was safe, supportive or enabled people to live their lives in line with what mattered to them. These failings placed people at ongoing risk of avoidable harm.

The provider failed to ensure risks were effectively identified, assessed, documented and managed. Risk assessments were not sufficiently robust. They did not consistently identify the reasons for risks or clearly set out the actions staff should take to reduce risks and keep both people and staff safe. This meant staff did not have clear guidance to support people safely or respond appropriately when risks arose.

Care planning documentation did not demonstrate how people had been involved in planning their care or how their views and preferences had informed decision making.

Where healthcare professionals had been involved in relation to people’s speech and language (SALT) needs, choking risks, and mobility needs, this information was not consistently reflected within the care plan. Associated risk assessments, including assessments for the risk of choking, were not in place. This meant staff did not have access to essential professional guidance to support the person safely and reduce known risks.

We asked the provider how people and their relatives were involved in care planning. The registered manager told us that families had access to the system and explained that the provider did not want to be solely responsible for care planning, that professionals and families were expected to contribute advice and guidance. However, the service delivering care and treatment for the person are responsible for ensuring the care planning and risk assessments are up to date.

The provider did not make sure that equipment, facilities and technology consistently supported the delivery of safe care.

One person required the use of equipment. Relatives we spoke with told us they did not feel staff were trained to use the equipment their relative needed to keep them safe.

Staff told us they had not received training to use specialist equipment prior to working with the person. We did not receive evidence that staff supporting the person had been trained to use this equipment safely. This meant the person, as well as staff, were at increased risk of harm.

The provider did not properly assess or manage the risk of equipment and their related risks to the person. There was limited guidance in place to enable staff to ensure they understood how to use the equipment. Risk assessments did not provide adequate information around the risks of the use of equipment.This meant the person, as well as staff, were at increased risk of harm.

The provider failed to ensure there were sufficient numbers of suitably qualified, skilled, appropriately recruited, supported and experienced staff to meet people’s needs. Failures in training oversight, workforce planning and governance placed people at significant risk of unsafe care.

The service had recently changed its training programme and was operating two different training systems simultaneously. The provider was unable to provide assurance that staff had completed the essential training required to safely carry out their roles. The registered manager told us that a health and safety group attended the service monthly to update staff training, however, there was no documented evidence to support this.

The training matrix was incomplete and did not include all staff working at the service. Of the staff supporting the person whose care we reviewed, three out of thirteen staff appeared on the matrix. One of the three staff members supporting the person, who appeared on the training, was recorded as having completed their training after the onsite inspection, and the other staff had only completed two trainings.

Mandatory training identified within the persons care plans was not recorded as having been completed. This meant staff were supporting the person without the required knowledge or skills, placing people at risk of harm.

Staff told us they were asked to begin working without receiving adequate training. Some staff reported they had not received training for a considerable period and described having to “learn on the job”. This further increased the risk that people were supported by staff who were not competent or confident to meet the person’s needs safely.

Recruitment and workforce oversight were ineffective. Staff interview records were not consistently available. We identified staff working more than the hours they were permitted to work. There were no effective systems in place to monitor working hours or ensure staff had sufficient rest periods between shifts. This represented a significant risk to staff wellbeing and people’s safety.

Relatives told us they did not feel staff were adequately trained to support their loved ones safely and were not always informed which staff members would be attending their home. This lack of communication and consistency created uncertainty for both families and staff and further undermined the delivery of safe and reliable care.

The provider did not always assess or manage the risk of infection. They did not consistently detect or control the risk of infection spreading, and concerns were not always shared promptly with the appropriate agencies.

There was no evidence staff had received training in infection prevention and control, which increased the risk that infection related needs would not be identified or managed safely.

The initial assessment for the person we reviewed completed by the local authority contained clear information about the person’s needs, however, this information had not been included in the person’s care plan.

The lack of accurate and detailed care planning meant staff did not have access to the guidance needed to provide consistent and safe support.

The provider failed to ensure that medicines and treatments were safe or met people’s needs, capacities and preferences. People were not consistently involved in planning their medicines or in decisions about how their medicines were managed. These failings placed people at significant risk of harm. Systems for medicines governance were ineffective, staff were not adequately trained, records were inaccurate and incomplete, and people were exposed to significant risk of avoidable harm.

The provider told us they did not administer the person’s medicines, however, daily care records documented that staff were administering medicines on a regular basis.

Medicines were being administered without clear authorisation, accurate medicines lists, medication administration (MAR) charts, or effective audit systems. The care plan instructed staff to administer the person’s medicines and referred to the use of “sleep medication”, directing staff to ensure all medicines were administered as prescribed. However, there were no MAR charts in place to evidence what medicines were prescribed. There were no risk assessments, protocols or guidance to support safe medicines management.

An audit carried out had identified staff were administering medicines, however, no action had been taken to ensure the correct documentation was in place. This demonstrated a serious lack of governance and put people at risk of medication errors.

Care planning documentation contained conflicting, incorrect and irrelevant information about medicines. Medicines listed in the care plan did not relate to the person. Where topical medicines such as creams or emollients were referenced, the care plan did not specify which products were prescribed. There were no body maps in place to guide safe use, and no topical MAR charts were in place.

Relatives told us they did not feel confident that all staff were trained to administer their loved one’s medicines safely and sometimes chose to administer medicines themselves to reduce the risk of errors. There was no evidence that staff had been trained to administer medicines, including specialist medicines, such as nasal sprays, further increasing the risk of unsafe practice.

The medicines policy stated that where a person lacked capacity to consent to medicines, a mental capacity assessment and best interest decision should be completed and recorded within medicines documentation. We found no evidence of mental capacity assessments or best interest decisions relating to medicines. When requested, the provider was unable to supply this documentation. This meant medicines were being managed without consent or clear evidence that decisions were made in the person’s best interests.