Xcel Homes 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.

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.

This service scored 53 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. However, lessons were not always learnt to continually identify and embed good practice.

Incident records showed the registered manager had reviewed events and actions had been taken to reduce the likelihood of recurrence. For example, if a person had experienced a fall, their care plan and risk assessment were reviewed and updated, and a referral was made to the relevant healthcare professionals for an assessment.

However, the provider did not have effective systems and processes to review, monitor, or analyse incidents, accidents, safeguarding concerns, complaints or electronic care calls. This lack of robust oversight and procedures to identify patterns, learn from events, and implement timely improvements limited the registered managers’ ability to drive continuous improvement across the service.

People were positive about how incidents were managed. A relative said, “They [staff] have a positive can-do attitude that problem solves. I feel very grateful for the care that we receive.”

Staff were aware of their responsibilities to respond to incidents, including how and when to report and what immediate actions may be required to maintain a person’s safety. A staff member said, “I have responded when people have been unwell or if there's been an incident. I have contacted the person’s next of kin, took the person’s observations, recorded and rang the office.”

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’s pre‑assessment document did not consistently record people’s important information. For example, details about the person’s lasting power of attorney, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) or any Advanced Decisions were not always recorded. However, this information was recorded in associated care plans.

Furthermore, the provider had no process to share essential details with other services when a person moved between settings. This meant people may have experienced a lack of consistency and continuity in their care.

We discussed these shortfalls with the registered manager who took some immediate actions to make improvements.

People and relatives told us before care commenced, a face-to-face meeting with a member of the management team had been completed. Positive comments were received about people’s experience of the pre-assessment process. A relative said, “[Name] from Xcel did a face to face visit and what I liked was how they focused immediately on [name] needs. I immediately took to them and felt confident.”

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. However, the provider had not consistently shared concerns quickly and appropriately.

A review of the provider’s systems and processes found where safeguarding incidents, concerns and allegations had been raised, the management team had reported these to the appropriate external agencies, such as the local authority and the police. This included taking actions to ensure people’s immediate safety. However, the provider had not submitted notifiable incidents to us, the Care Quality Commission (CQC), as required. This information is essential for monitoring the quality and safety of services and helps ensure people receive safe and effective care. Following our inspection, the provider submitted the required notifications.

Peope and relatives told us they had no concerns about safety. A person said, “I have no concerns about safety. New staff are introduced and shadow other staff first. Staff wear a uniform and have an ID badge.“ A relative said, “We had an issue with one of the staff a long time ago, but this was nipped in the bud, the manager responded immediately.”

Staff had access to the provider’s safeguarding policy and received refresher safeguarding training. Staff were aware of their responsibility of protecting people from risk and avoidable harm. A staff member said, “We have a duty to protect people from harm. Any concerns are recorded and reported to the manager. I feel confident the manager would respond positively and immediately to any concerns.”

At the time of the inspection, no person had a Community Deprivation of Liberty Safeguard (DoLS) in place that imposed restrictions on them for their safety.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, from reviewing a sample of people’s risk assessments, we identified some examples where information was inconsistent, lacked detail or was missing.

For example, one person had a diagnosis of diabetes, and another experienced frequent urinary tract infections which they were unable to recognise themselves. However, guidance for staff did not outline the signs and symptoms of deterioration or the actions staff should take in response. Where a person had a mental health diagnosis, staff were expected to monitor for changes, yet there was no information describing how the person might present when unwell or what steps staff should follow to ensure their safety.

Whilst this placed people at an increased risk, this was mitigated by the fact that people received care from consistent staff who knew them well. Staff demonstrated a good understanding of known risks and were able to explain how these were managed and mitigated in practice. We were sufficiently assured that this was primarily a recording issue rather than a lack of staff knowledge. The registered manager assured us they would review all risk assessments and improve the quality of recorded guidance for staff.

People and relatives were confident that known risks associated with care needs were safely managed. A relative said, “Having regular care staff means they spot any slight changes or differences with [name] health conditions and known risks, and they feedback any changes immediately to me.”

Staff told us how known risks and changes to people’s care needs were managed. A staff member said, “Guidance is updated when changes occur. The manager may phone to tell us of anything we need to know immediately, we also have a weekly staff meeting. This is really helpful, and we share any important information about people's needs, changes and anything else.”

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.

An assessment of the environment had not been completed to ensure staff were aware of important information that would assist them in the event of an incident affecting the environment or premises. There had also been no consideration of known environmental or safety risks that could impact either the person or staff. We discussed this with the registered manager who agreed this was an oversight. However, they agreed to implement an environmental risk assessment as a priority.

Staff promoted people’s safety and independence by making referrals to external health and social care professionals for equipment, such as aids and environmental adaptations.

Staff felt safe working in the community. New staff shadowed experienced staff before working independently.

The provider had a lone working policy and an out-of-office procedure. Staff confirmed this was helpful and supportive.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. However, some shortfalls were identified in staff support.

For example, the provider had recently changed the accredited training company they used. The registered manager provided training data that showed gaps in refresher training that was overdue. The registered manager assured us mandatory training (training that the provider had identified as required) was up to date. The registered manager agreed to review all staff training as a priority.

Records showed gaps in 2024 and 2025 of staff supervision, appraisals and spot checks. The registered manager agreed they had not been completed at the frequency they expected. However, with a new addition to the management team, improvements were being made and plans were in place.

Staff were positive about the support they received. They confirmed the management team were available for support and guidance when required. A staff member said, “My manager and supervisor are really supportive, they are very good, they are always available and responsive if I need any help.”

The provider had safe staff recruitment procedures. These checks were completed before staff commenced, ensuring only suitable candidates with the right skills and experience were appointed.

People and relatives told us they found staff to be “experienced, knowledgeable and competent”

They also confirmed staff usually arrived at the expected time and stayed for the duration of the call. A relative said, “Staff are always on time and stay for the duration, yes definitely. They always go above and beyond and ask if they can do any more. Sometimes, I have to say, ‘No it's time to go.’”

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.

Staff had received training in infection prevention and control (IPC). They had access to the provider’s policy and personal protective equipment (PPE).

The management team completed spot checks on staff to ensure they were providing care in line with expected standards and the provider’s policies. These records confirmed that checks included infection prevention and control (IPC) practices.

People confirmed staff wore appropriate PPE, including gloves, aprons and masks when required.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. However, best practice guidance for medicines management was not consistently followed.

For example, PRN protocols (prescribed medicines administered when required) were not in place. This meant staff did not have clear guidance on when to administer these medicines or how to monitor their effectiveness. There was no evidence that emollient creams had been subject to a fire risk assessment. Topical cream administration records did not include a body map to show the site of application. Medicine care plans recorded the medicine name and dose, but did not include specific details such as the time of administration, the route, the purpose of the medicine, or any potential side effects. This is important information to ensure people received their prescribed medicines safely and consistently.

No person had come to harm, and we concluded this was a recording issue. We discussed this with the registered manager team who agreed to take action.

People and relatives raised no concerns about the support provided by staff with medicines.

Staff had completed medicines refresher training, and their competency was assessed annually or more frequently if required.