Delight Services Limited Also known as Delight Care

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.

The service was in breach of legal regulation in relation to staffing.

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 did not have a consistent proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. The provider’s systems and processes regarding how lessons were learnt to continually identify and embed good practice required strengthening.

During the inspection site visit, the registered manager was unable to provide evidence of oversight systems used to monitor and review accidents, incidents, quality, or learning outcomes.

After the visit, the registered manager sent an electronic monitoring report covering missed and late calls and feedback from people over the previous 12 months. While this included some examples of learning, we were not assured that information was being systematically analysed, incorporated into improvement plans, or used to drive sustained change. It was unclear how themes were identified, how actions were monitored, or how learning was shared with staff.

The service improvement plan did not set out identified improvements, required actions, or responsible persons.

The registered manager told us no complaints had been received and that any concerns had been responded to, but no evidence was available to confirm this. They also stated that satisfaction surveys had not been completed, this was despite complaints and satisfaction responses being referenced in the provider’s monitoring report and internal audit. This inconsistency meant we were not assured that oversight systems were robust or effective and indicated they required strengthening.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. However, there was no systems and processes to ensure continuity of care, including when people moved between different services.

The provider’s systems and processes in relation to their pre-assessment procedure, including care plan guidance for staff did not consistently record important information and decisions to support consistently and continuity of care. 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 consistently recorded. This meant staff did not always have access to essential information to guide safe, person‑centred care or respond appropriately in an emergency.

Furthermore, there was no procedure to share essential information with others when a person moved between settings. For example, ambulance and hospital staff. This lack of planning may have impacted a person experiencing unsafe and inconsistent care.

A person using the service and relatives confirmed a face to face pre-assessment had been completed before care commenced.

From a sample of pre-assessment records reviewed, we found multiple gaps in information. This meant staff did not have a full understanding of people’s needs, preferences or risks from the outset, increasing the likelihood of inappropriate support, inconsistent care planning and delays in identifying the right level of care required.

The provider did not consistently work 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. The provider did not have robust systems, processes and oversight of safeguarding and actions required of them to share information quickly.

The registered manager told us how staff were required to respond to any accidents, incidents and safeguarding’s by recording and reporting. Staff also understood their responsibilities. However, there was no system and process by the registered manager to review these events for themes, patterns and learning. From the audit information shared, this did not reflect any incidents had been reviewed. The registered manager agreed their systems and processes needed to be strengthened and improved upon.

The registered manager told us of a recent police incident in relation to a safeguarding concern. They assured us this had been reported to the local authority. 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 notification.

People and relatives told us that staff did not consistently wear a uniform or ID badge. They did confirm they felt staff provided safe care. It is important staff were an ID badge to ensure people can clearly identify who is providing their care, feel confident that staff are legitimate workers, and maintain professional boundaries and safety. We shared this with the registered manager to follow up with staff. They confirmed that staff were provided with both an ID badge and uniform.

Staff were aware of their responsibilities to protect people from abuse and avoidable harm. A staff member said, “Safeguarding means that we've received training to identify any form of neglect and or abuse, we make sure people are safe and report any safeguarding concerns.” And, “Whistleblower means we should report any poor practise by staff, I did raise a concern yes, this was when I was working in Tamworth, the manager took immediate action and improvements were made.”

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 did not consistently work with people to understand and manage risks by thinking holistically. Whilst staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them, guidance to ensure consistency and safety was not always detailed.

Risks associated with people’s care needs and support was not consistently assessed, planned for and mitigated. For example, a person’s risk assessment dated April 2026 stated, ‘Blood Pressure Fluctuations, scheduled monitoring (twice weekly) - Record and escalate abnormalities and review weekly.’ However, staff were not provided with any guidance of how to take blood pressure accurately, what constitutes an abnormal reading, when and how to escalate concerns, who to escalate to and how to document readings. This omission placed the person at potential serious health implications from poor blood pressure management.

We received mixed feedback from people and relatives about risk management. One relative told us how their family member could often refuse their medicines, but this known risk was not recorded in the person’s risk assessment. Another relative believed at times only 1 staff attended their family member’s care call when 2 were required. We raised this concern with the registered manager to follow up, as they refuted this.

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, including fire that could impact either the person or staff.

The registered manager told us during their visits to people, they reviewed the environment for any risks, however, advised they did not record this.

Staff told us they had shadowed experienced care staff before working independently. They were positive about the support and responsiveness of the registered manager, including out of hours support.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The staff training matrix showed permanent staff had not all completed the 23 training topics the registered manager had identified as required. This included essential training in learning disability and autism, and Oliver Mc Gowan mandatory training, which is a legal requirement for all health and social care providers in England.

Staff competency assessments had not been completed in any area of care delivery. The registered manager told us moving and handling had been observed but not formally recorded. This meant the provider could not be assured that staff had the necessary skills and knowledge to deliver care safely and consistently.

The registered manager told us they completed unannounced spot checks to review staff’s practice. However, these were not formally recorded, and they were unable to evidence when these had been completed.

Staff supervision information showed 2 care staff were not recorded. This is despite the staff training matrix and information from the registered manager that confirmed they were permanent employed care staff. We therefore were not assured these staff had received supervision.

We received no evidence that staff had received an annual appraisal. The registered manager informed us staff appraisals had taken place but were unable to confirm this.

Staff were positive about the support they received from the registered manager. They told us they attended 4 staff meetings a year and met with the registered manager on the last Saturday of the month. The Registered Manager confirmed this was to talk about their work, feedback and any concerns. However, the registered manager told us this was not formally recorded.

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. However, staff recruitment files had not been maintained to reflect who was currently working for the provider and who had left.

Overall people confirmed staff arrived on time or within 30 minutes of the expected time. One person gave an example of how staff worked longer than the expected call duration, whilst another raised a concern about care calls sometimes being shorter than expected.

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 personal protective equipment (PPE).

We received mixed feedback about staff using PPE. Comments included, “Staff wear gloves 100% of the time, not always aprons.” And “Yes, staff wear PPE.”

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

The systems and processes in the management of medicines showed the provider’s medicines policy was not being followed. In addition, best practice guidance, including the National Institute for Health and Care Excellence (NICE) Guideline NG67: Managing medicines for adults receiving social care in the community, had not been adhered to. This guidance sets out nationally recognised standards for how medicines support should be assessed, delivered, recorded and reviewed for adults receiving social care in their own homes or community settings.

For example, Medicine Administration Records (MARs) were not used to record when staff had supported people with their medicines. This meant there was no reliable audit trail to demonstrate whether medicines had been administered safely, at the correct times, or in line with prescriber instructions. It also meant staff could not easily identify missed doses, errors or patterns of concern, increasing the risk of harm.

Not all staff had completed medicines training, and no staff had their competency assessed. The staff training matrix showed 4 out of 7 staff had completed medicines training in 2024. This meant the provider could not be assured staff had the necessary knowledge or skills to support people with their medicines safely.

Care plans lacked important guidance for staff about people’s medicines. For example, details of who was responsible for the ordering, collection and return of medicines were not recorded. This meant staff did not have the information they needed to manage medicines safely or ensure responsibilities were clearly understood and consistently carried out.

One person’s risk assessment stated the following: ‘Staff to administer medication, maintain MAR charts, monitor side effects.’ However, staff had no guidance on the possible side effects to look out for. In addition, people’s routines and preferences for how they took their medicines were not recorded. This meant staff did not have the information needed to support people safely or in a way that reflected their individual needs and choices.

Overall, people and relatives were satisfied in how staff provided support with medicines.