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Extra Hands of Heacham Limited - Broadland Office Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 12 June 2021

About the service

Extra Hands of Heacham Limited is a domiciliary care service. They provide personal care and support to people living in their own homes. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of our inspection the service was providing the regulated activity to 140 people, 34 of whom were supported with medicines.

People’s experience of using this service and what we found

The provider had not developed full, accurate contemporaneous records relating to all relevant aspects of people’s care. This included full records with guidance and risk assessments around people’s needs, health conditions and medicines. They were developing a new electronic care planning system to include all areas of people’s care.

Improvements were needed around the recording and administration of people’s medicines.

People received care from staff who were knowledgeable about the risks associated with people’s care and received effective training related to keeping people safe, including managing risks associated with their health and safeguarding people from harm.

Staff were recruited safely and cared for a consistent group of people they knew well. People received a responsive, person-centred service from competent and caring staff, and they knew how to raise concerns.

There were infection control measures in place which contributed to protecting people from, and managing risk of infection, including from COVID-19. This included staff wearing full personal protective equipment (PPE) during care visits.

There was a strong positive working culture in the service and good teamwork amongst the staff. People, their families and staff felt involved in the ongoing service delivery and were informed about changes.

We have made two recommendations in relation to care planning around risk and end of life.

For more details, please see the full report which is on the CQC website at

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 02 October 2019) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

This was a focused inspection to look at Safe, Responsive and Well-led. This report only covers our findings in relation to these three key questions. We have found evidence that the provider needs to make improvements. Please see the well-led section of this full report.

We found no evidence during this inspection that people were at risk of harm from this concern. You can see what action we have asked the provider to take at the end of this full report.

We reviewed the information we held about the service and no areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from the previous comprehensive inspection for those key questions were used in calculating the overall rating at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Extra Hands of Heacham Limited on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We have identified a continued breach in relation to good governance at this inspection.

Please see the action we have to

Inspection areas


Requires improvement

Updated 12 June 2021

The service was not always safe.

Details are in our safe findings below.



Updated 12 June 2021



Updated 12 June 2021



Updated 12 June 2021

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 12 June 2021

The service was not always well-led.

Details are in our well-Led findings below.