During an assessment under our new approach
Date of Assessment: 13 April 05 May 2026. The service is a care at home service providing personal care to people living in their own homes. At the time of our assessment there were 4 people receiving personal care. We carried out this assessment following a review of the information we held about the service. This was the first inspection since the provider registered with the Care Quality Commission (CQC) in February 2022.
At the time of our assessment, we found the provider was delivering care that did not fully align with their registration conditions. The provider has a condition in place which restricts them from supporting people whose primary presenting need is a learning disability or autism.
The provider was supporting 2 people with a diagnosed learning disability. Although the provider told us both people’s primary need was physical health, 1 person was receiving a 24-hour care package. This meant staff provided continuous support, including aspects of care related to their learning disability. We discussed this with the provider and advised them to submit an application to CQC if they intended to continue supporting people with these needs, to ensure their registration accurately reflected the care being delivered. The provider told us they would submit this immediately. Staff demonstrated a good awareness of people’s needs, and the provider had delivered training in this area.
Governance systems did not provide sufficient oversight of the service. Although the registered manager told us they visited people frequently, they did not consistently record these visits, which limited evidence of oversight. The provider’s quality assurance processes had not identified the concerns highlighted during this inspection, reducing opportunities for learning and improvement.
Risk assessments were robust; however, the provider needed to strengthen monitoring arrangements to ensure staff followed guidance within care plans. Mental Capacity Act documentation was not always clear or decision specific. Care plans were detailed and included specialist guidance where required.
Recruitment processes did not always ensure risks were fully mitigated and required improvement.
People received care from staff who treated them with kindness and respect. Care plans reflected people’s preferences, routines and cultural needs. Staff had access to detailed communication guidance to support people with complex needs.