During an assessment under our new approach
Date of Assessment: 8 May 2025 to 19 June 2025. The service is a care at home service providing support to adults of all ages living in their own homes. We gathered information from relatives of people who used the service, the registered manager, health and social care professionals and care staff.
Recruitment records were not always in line with best practice guidance. Gaps in employment had not been accounted for, and appropriate references were not always obtained. The failure to safely recruit staff is a breach of regulation 19 (fit and proper persons employed). We found no evidence that people had been harmed, however, there was the risk of potential harm.
The provider had not submitted CQC statutory notifications in line with requirements. The failure to submit notifications is a breach of regulation 18(reg) (notification of other incidents).
Care records were not always person-centred; some documents were contradictory. Risk assessments did not always identify the risks to people or demonstrate actions had been taken to keep people safe. The provider’s quality assurance audits had not identified the issues we found. The failure to maintain appropriate care records, mitigate risks and have effective governance systems is a breach of regulation 17 (good governance). We found no evidence of negative impact on people using the service, however, there was a risk of potential harm.
Staff built up a good rapport with people who they cared for. The registered manager and provider had oversight of the service. Staff said the registered manager and office staff were approachable and supportive. Health and social care partners gave mixed feedback about the management of the service.