Head Office

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 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 ensure there was a proactive and positive learning culture.
The provider told us they had a system in place that recorded when theoretical incidents may occur. We viewed these and saw theoretical incidents were recorded, such as; when vehicles may break down, when there was staff sickness and when there was a lack of access to the office. The action that would be taken in response to the incidents was also recorded. However, there was no record to show what action had been taken or considered when actual incidents had occurred, or how these theoretical incidents had been implemented into practice. Where we found concerns with the timing of care calls, this had not been considered. This showed improvements were needed to the learning culture at the service.

The provider did not always ensure, establish and maintain safe systems of care.

There was a pre assessment process in place which ensured people’s needs could be captured and met before they started using the service. However, improvements were needed to ensure all areas of these assessments were used to develop appropriate care plans and risk assessments. For example, when people had been identified at risk of developing sore skin or having a health condition there was not always further care plans or risk assessments in place to ensure staff had the necessary guidance available to support people safely.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

People felt safe being supported by staff and relatives raised no concerns. One person said, “They treat me gently so that makes me feel safe.” A relative told us, “My relation is safe with them”.

Staff told us they had received safeguarding training. They were able to tell us the action they would take if they had concerns. One staff member said, “It is protecting vulnerable people. I would add the information to the app. Alert the office and they would share the information.” There were safeguarding procedures in place to ensure concerns were identified and reported.

The provider did not always work well with people to understand and manage risks.

Care plans were not always consistent, up to date or in place. Some of the care plans we viewed lacked detail or were not accurate. For example, some people’s care plans had not been updated to reflect their current calls times. When people had been assessed as ‘at risk’, care plans had not always been developed, for example for diabetes and when they were at risk of developing sore skin. Other people did not have care plans in place when needed. For example, when they had specific health needs.

The provider told us they were using both a paper and an electronic system to monitor care. We gave the provider the opportunity to send us this information after the site visit. The information we received did not confirm that care plans were sufficiently detailed and accurate. This meant people were at risk of harm because accurate information was not always available to guide new or temporary staff in how to provide safe care and support.

Despite this, we found no evidence to suggest people had come to harm because of these concerns. This was because the staff we spoke with knew people well and were aware of people’s individual risks and how these risks should be managed.

People and relatives were happy with how their risks were managed. One person gave an example of how they had worked with the staff who visited them to manage a specific risk, they told us how they had tried different ways of working until they had found a solution.

The provider detected and controlled potential risks in the care environment.

There were systems in place to ensure environmental risks in people’s homes and surrounding areas had been considered. We saw people had risk assessments in place that related to their environment. Staff we spoke with were aware of these assessments and any risks that they needed to be aware of.

The provider did not always ensure care was delivered at the correct times for the correct amount of time.

We received mixed feedback on staffing. One relative raised a concern with us about the time staff stayed at the call. They told us, “My issue is they leave when they have finished. I think they should do more. I am paying for half an hour they should find things to do for the half an hour. They just leave”. Other people and relatives we spoke with felt there were enough staff, and that staff had the skills to look after them well. One person said, “We have a regular carer who knows me well. They always come on time. We’ve had some minor changes, but they still do everything they should. They stay the full time”. A relative told us, “They more or less arrive on time every day. If they are running late, they let us know if they can. If they are late, it’s not their fault it’s the traffic or something.”

There were systems in place to plan for and ensure there were enough staff available to support people at the right times. However, the records we viewed showed calls were not always on time as planned for or for the correct duration. We viewed a visit time report for March 2025. This showed calls were often over 20 minutes late and 1 call that was 1 hour and 55 minutes late. There was no further information or an audit available that showed why this was or the action taken.

Staff had received the relevant pre-employment checks before they could start working with people to ensure they were safe to do so.

Staff had received training to ensure they had the relevant knowledge and skills to support people.

The provider assessed and managed the risk of infection.

People and relatives raised no concerns with infection control. One person said, “They always wear gloves and aprons and sometimes masks”.

Staff confirmed they had received training in this area and Personal Protective Equipment (PPE) was stored in people’s home so it was available for them to use. There were processes in place that were followed to ensure staff protected people from the risk of cross infection.

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

Staff had received training to administer medicines, however their competency was not regularly checked to ensure they were safe to administer medicines to people.

After our site visit the provider sent us a competency checklist that they would be introducing with staff. We will review this as part of our next inspection.

When people were prescribed ‘as required’ medicines, protocols were not always in place to ensure staff had the guidance available to ensure people received these medicines as prescribed.

However, people and relatives raised no concerns with how their medicines were managed. The records we viewed confirmed people had received their medicines as prescribed.