Updated 29 June 2026
Date of Assessment: 30 June to 21 July 2026. This was a follow up assessment to check if improvements had been made following our previous assessment triggered by our ongoing monitoring of the service. The service is a care at home service providing support to adults of all ages living in their own homes. CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. At the time of the assessment 22 people were using the service.
The provider was previously in breach of the legal regulations in relation to safe care and treatment and good governance. At this inspection the provider had not improved sufficiently, and were still in breach of the legal regulations in relation to safe care and treatment and good governance.
The provider was motivated to learn and improve the service for people. However, improvement was limited by a lack of effective risk and quality monitoring systems. This meant effective action had not been taken to address shortfalls found at our previous inspection and ongoing shortfalls we found in relation to people’s risk assessment and risk mitigation plans had not been identified prior to our inspection.
Although staff understood and managed some risks related to people’s care, they did not understand them all. This included the risks related to creams and lotions or pressure ulcers. Risks were not always assessed in accordance with universally recognised tools and documented in people’s care plans. This was also confirmed by professionals involved in people’s care.
The provider only made 1 staff recruitment file available for review as the registered manager was unable to provide the other files we requested. The lack of recruitment records meant they failed to demonstrate safe recruitment requirements.
Records did not show how people’s mental capacity had been assessed or if any best interest decisions were made on their behalf when required to ensure their rights and freedom were protected.
People and relatives knew how to complain and were confident the provider took it seriously and acted on it. People were protected and kept safe from abuse. Staff were happy to raise any safety concerns and felt they would be dealt with properly. There were sufficient numbers of staff in place.
People were consulted around how they wished their personal care to be carried out. However, people’s care had not been planned to take account of all their needs. Records did not show reviews of people’s care were taking place to ensure care plans were up to date.
People had a good level of consistency in care staff. Although people and relatives were generally positive about staff, they wanted to have rotas to tell them who was coming, especially if regular staff were not available. Although staff received training appropriate to their role, records of staff competency were not accurate. This included competency checks for medicines and manual handling. Team meetings were held online although we were unable to check their content or attendance.
The registered manager had worked with an external consultant to produce an action plan from the previous assessment with areas of improvement. However, they were not able to evidence where this had been completed. The provider was unable to show us any evidence of learning from incidents, complaints, or feedback from people or staff.
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