Heart of Gold Homecare 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 requires improvement. At this assessment the rating has remained the same. 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.

The provider breached regulations in relation to safe care and safeguarding. The registered manager was completing competency assessments with staff members in relation to percutaneous endoscopic gastrostomy (PEG) care, medication management and moving and handling, despite them not having the qualifications or experience to do so. The registered manager had failed to identify 2 safeguarding concerns which were picked up by the CQC and the local authority and failed to escalate 1 of them.

This service scored 59 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Learning from incidents was not always consistently embedded or consolidated.

A person told us they had raised 2 concerns with the office on the first day of the inspection. These concerns were not documented on the concern log, despite this being sent to us 3 days later. This showed when people raised concerns, the concern log was not always used to proactively identify, manage and control risks.

The provider reported to us there had been 4 incidents in 2025. The last 3 incident reports, completed by the registered manager, were reviewed. Findings included body maps not always being completed, a safeguarding concern not being identified or escalated to the local authority, the reflection section of the forms not being fully completed so immediate actions were missed and reflections not always being accurate. The lessons learned section from the incidents were comprehensive, however, they did miss key actions including the need to report to safeguarding.

The provider confirmed they had received no formal complaints in 2025. They kept a log of concerns raised. In 2025 there had been numerous concerns raised across very similar themes which included meals, nutrition, security, household tasks and personal care. Whilst the provider had confirmed them to be minor in severity, the repeated patterns suggested systemic gaps in staff training or adherence to care plans. The actions taken were mainly reactive, rather than proactive and most actions involved reminding staff after an incident of the appropriate procedures.

The provider had an improvement plan for strengthening reporting and learning which included some objectives to strengthen the accuracy, completeness and timeliness of incident reporting, but there were no indicators of when this had been produced meaning we were unaware of if the actions should have already been achieved. The improvement plan also referenced how incident themes were reviewed at team meetings, but this was not the case.

Staff understood what constituted an incident or accident. All staff knew to report concerns to the registered manager; however, most were unaware of the requirement to record the incident on an incident log.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care.

We received very limited feedback from partners in relation to systems, pathways and transitions. The partner we did receive feedback from felt the registered manager could work with them better to resolve issues which had been identified. The partner felt the service was a ‘moderate concern’ and an improvement plan was in place.

Care and support were not always appropriately planned and organised together with partners or communities. We did not see evidence of collaborative care plans for people who had care from external healthcare professionals.

The registered manager told us they completed pre assessments with people before they entered the service which informed the care plans. We saw some of these and they contained an appropriate amount of detail.

The provider had a 1-page profile for each person supported which provided a concise overview of the person based on their support plan. The registered manager told us these were used as ‘hospital passports’ when required. On review, we requested the profile to be updated to contain the person’s current medication. Following this feedback, the provider responded and updated this by the end of the day.

Staff did not always have a good understanding of safeguarding. The provider did not always identify safeguarding concerns and therefore did not share them with the appropriate agencies.

There was some understanding of safeguarding and how to take appropriate action, but safeguarding was not always given sufficient priority or applied consistently.

Immediate action was not always taken to keep people safe from abuse. Whilst reviewing incidents, we identified a safeguarding concern which had not been followed up on by the registered manager. In the incident review form, the registered manager had noted they would consider a safeguarding referral, but this had not been completed. The registered manager told us they had met with the person, their social worker and family, but this had occurred 16 days later and although the concerns were discussed, the initial rationale for the meeting was a review of the person’s care package. A further safeguarding concern had also been identified by a pharmacy technician from the local authority when they had completed a visit. These safeguarding incidents were not initially recorded on the provider’s safeguarding log and the CQC had not been notified of the 2 safeguarding concerns. Notifying CQC of safeguarding concerns is a requirement of a provider. When the registered manager was made aware, they said they would ensure the notifications were submitted and would submit safeguarding concerns in the future.

The provider had a safeguarding policy and ensured staff had access to training for safeguarding adults and children. However, there were multiple courses available to staff. Some staff had completed advanced safeguarding training prior to foundation and intermediate levels, which does not follow best practice sequencing. Staff should have developed core knowledge first, then progressed to role appropriate higher levels to ensure understanding was built in a structured and safe way.

Despite training being completed, some staff did not have a good understanding of safeguarding, including important signs and symptoms to be considered and the different types of abuse people are susceptible to. All staff knew the process if they were to identify a safeguarding concern, but we were not assured all staff would be able to obtain this information in the first instance.

People and their relatives told us they felt safe and had not experienced abuse or neglect.

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.

People were actively involved in identifying potential risks within their daily routines, and staff took time to understand what they perceived as unsafe and challenging. People and relatives said they were involved within care planning. A person specifically said, “Yes, they always involve us in care planning”, whilst a relative said, “Yes, they include me in decisions for [relative’s] care.”

Staff were informed about and understood the risks relating to the people they supported.

Staff supported people to make informed decisions about how risks were managed. Where people chose to take positive risks, these decisions were respected and clearly documented.

Staff used clear, accessible language which ensured people and their relatives understood their risk assessments and the steps in place to keep them safe.

The provider completed a recent survey in which the standard of care was reviewed by people using the service. From 12 reviews, all were positive regarding care. A person said, “Yes, all my needs are being met” whilst another person said, “Carers understand what I require and support me well with daily tasks.”

The provider had emergency protocols in place which staff could follow. The diabetes management emergency protocol clearly identified the early warning signs for hypoglycaemia and hyperglycaemia (low and high blood sugar levels) and immediate actions necessary which included notifying the office manager or urgent medical help.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff completed risk assessments for equipment used by the person within their property. The risk assessments were completed by senior staff members who had additional competencies and training to do so.

People’s support plans contained a safe environment section which reviewed any risks including fire hazards, unsafe pathways and trip hazards. The fire evacuation procedure was confirmed within this section, and an environmental needs assessment was completed which was person centred.

The registered manager did not have the training to complete competency assessments for staff. Staff’s compliance with training needed improvement. However, recruitment practices were safe and there were appropriate staffing levels.

The registered manager was completing competency assessments for staff. Despite the registered manager having completed the training with staff, they had not completed their ‘train the trainer’ qualification and were not a practicing clinician. This is unsafe as an assessor must know the risks in detail to identify any unsafe practice and in this case improper practice could lead to significant harm including aspirational pneumonia, blocked PEG tubes and injury.

The provider’s training matrix, which records staff completion of required training modules, identified variation in compliance levels. While some staff demonstrated high completion rates, others showed significantly lower compliance; for example, a staff member had completed only 39% of the available courses.The provider’s training policy did not indicate how frequently ‘In-house’ training should be completed, so we were unsure whether some staffs training had expired as it had been over 3 years since their last face to face course.

The training matrix which showed staffs completion of e – learning modules indicated how some staff had completed multiple modules in a single day with a staff member completing 20. This volume of learning in a short period, risks reducing the effectiveness of training and may impact staff competency.

The registered manager provided evidence of completed supervision documents. However, for some staff members these were almost identical which raised concerns whether the supervision was meaningful and reflective. Feedback or suggestions raised within supervision were not always identified as agreed actions.

The registered manager told us spot checks were being completed. The registered manager provided us with the spot checks which had been completed in 2025, and we found there to be 59 which was appropriate for the size of the team and the amount of people being supported.

The provider had been identified earlier this year as having shortfalls regarding their safe staff recruitment checks. This was reviewed on the inspection, and apart from 1 staff member having started their employment before their Disclosure Barring Service (DBS) checks had come back without any concerns on it, the staff files contained the appropriate documentation. Application forms were fully completed, and at least 2 references were obtained prior to staff starting work. Interview questions and answers forms were kept, however interviews were completed solely by the registered manager. Whilst no direct evidence of unfair outcomes was observed, having multiple interviewers is recommended to enhance the integrity and fairness of the process. The registered manager responded well to this feedback and made amendments following the inspection.

The provider ensured calls were delivered on time, calls were completed for the correct length of time, and they were logged appropriately. People confirmed this and were happy with the timeliness of staff and the amount of time staff spent with them.

New staff completed an induction when they started with the service. The provider had processes in place to ensure staff were competent before starting their roles which included shadowing and competencies being signed off during a probationary period.

The provider assessed and managed the risk of infection.

The providers office environment was clean, tidy and well organised.

Staff had received appropriate training in IPC and were knowledgeable of when they should wear PPE and when they should remove it.

The provider ensured IPC was included within care records which were reviewed regularly. People and relatives told us staff members wore the appropriate PPE when required.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Care plans for service users were person-centred and detailed. However, some sections of the care plans had out of date medicines related information in them, including doses and regimes. It wasn’t always clear when staff had responsibility for administering medicines.

No missed doses were evident for the service users we looked at. However, some administrations were documented by 2 different carers which could lead to confusion. Where family administered medicines to service users, this was not always clear on medication administration records (MARs).

People that were prescribed ‘as and when required’ (PRN) medicines had protocols in place to show staff how and when to use these medicines. However, they often contained incorrect information and weren’t reviewed regularly.

Lists of all prescribed medicines from GPs were kept for each service user, but not all items were prescribed on the MARs. This could lead to staff being unable to administer items which were not documented on the MAR, including emergency epilepsy medicines.

Where variable doses were prescribed, e.g. 1 to 2 tablets, the doses given were documented within the daily notes. Appropriate time intervals were clear when PRN doses were given to ensure they were given safely. Times of administration were consistent during care calls.

If an incorrect entry was made on the MAR, this was clearly documented in the daily notes.

People that were prescribed their medicines to be given via a percutaneous endoscopic gastronomy (PEG), or feeding tube, had details documented in the notes on when this had been completed. However, there was no information provided from a pharmacist to ensure these medicines were safe to be given this way.

People that were prescribed thickener, to reduce the risk of choking, had documentation within their daily care notes to show how much had been given by carers. The hospital letter confirming the correct thickener dosage was not available, so we were unable to verify whether the amount administered was accurate.