Continuity Health Care Services PVT Limited

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• 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

This means we looked for evidence people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, safe medicine management, and safe and effective staffing.

This service scored 34 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The service did not demonstrate a safe learning culture, and leaders were not effectively identifying, sharing or acting on learning to prevent avoidable harm. Incidents, concerns and safeguarding alerts were not consistently analysed to review trends, patterns and themes. There was no structured approach to understanding why things had gone wrong. As a result, the same issues continued to reoccur without meaningful action being taken.

Opportunities to learn from incidents, concerns, and feedback were frequently missed, and actions taken were reactive rather than proactive. This meant the service did not consistently identify patterns, reduce risks, or embed meaningful change. As a result, improvements were not sustained, and people were exposed to avoidable harm because lessons were not fully understood, shared, or implemented across the service.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The provider did not have safe or robust systems in place to manage pathways and transitions into the service. Although people’s needs were assessed prior to care commencing, the significant growth in service provision including an increase in new care packages was not supported by effective oversight or planning.

Transitions, particularly for people discharged from hospital, were poorly managed. We found examples where care plans and risk assessments had not been completed by the management team before care had started. In two cases, essential information was not shared with staff until several days after support had already begun. This meant staff were providing care without the necessary direction or guidance to ensure people were supported safely during a critical period of transition exposing people to the risk of avoidable harm.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

The provider had processes in place to ensure safeguarding concerns were reported to the relevant organisations, and systems existed to investigate and review individual safeguarding incidents. There was evidence of open and transparent reporting and working with investigating authorities, for example, for incidences of self-neglect and potential harm. However, the systems were not always effective in protecting people from harm.

When we reviewed the provider’s safeguarding audit, we found actions intended to prevent further harm had not been fully embedded by the registered manager. For example, actions relating to recurrent safeguarding concerns around pressure care had not been implemented at the time of inspection. This included the failure to introduce two‑weekly reviews of people’s care plans, update risk assessments, and ensure daily monitoring was consistently completed. As a result, the service could not be assured risks to people were being adequately reduced.

The registered manager upheld their responsibilities to ensure correct processes were in place where people were deprived of their liberty

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider did not ensure people were safely supported to manage risks associated with their health conditions. People with acute clinical needs, such as PEG (enteral feeding tube) management, catheter care, and pressure or wound care, did not have adequate risk mitigation plans in place for staff to follow. For example, one person’s PEG risk assessment lacked essential information to guide staff on the safe administration of medicines and nutrition, and the prevention of infection.

Risk management plans for people requiring catheter or wound care were generic and did not provide the specific, person-centred detailed guidance needed for staff to respond appropriately if risks arose. Additionally, staff failed to consistently record the care provided or actions taken in relation to managing health conditions within daily notes, limiting the management team’s oversight of risk management. Furthermore, care plans were not always updated with clinical professionals guidance and therefore staff were not provided with the most relevant and safest advice. This placed people at significant risk of avoidable harm.

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.

The provider did not always ensure people were supported in safe and well‑maintained home environments.

Staff were aware of their responsibilities in relation to environmental risks within people’s homes; however, these risks were not consistently identified, assessed, or reviewed. Concerns were not always evaluated effectively, which meant potential hazards including access issues, unsafe equipment, and fire risks could place people at risk of harm. Although fire risk assessments and internal and external environmental checks had identified potential risks to staff and people, appropriate actions had not been taken to mitigate them, nor had clear guidance been developed to support staff in keeping people and themselves safe during care visits. As a result, the provider could not be assured that people’s home environments were consistently safe or that associated risks were being managed effectively.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider did not have effective systems in place to ensure staff were competent or their performance was appropriately monitored. This meant the registered manager did not have assurance that staff had the necessary skills to deliver safe care. For example, staff supporting a person with a PEG in situ had not received the required training, nor had their competency been assessed by a relevant health professional to confirm they could carry out this clinical task safely. This meant people were exposed to unsafe care and treatment.

Additionally, the provider’s planned and actual ECM (electronic care monitoring) data, which should have given the management team oversight of people’s call times, including attendance and duration, had not been reviewed effectively. As a result, the registered manager could not be assured people were receiving care in line with their commissioned hours or personal preferences.

We reviewed the providers ECM data from October 2025 to December 2025. We found multiple examples of people affected by late or early calls, staff not remaining for the full duration of planned visits, and occasions where individuals who required 2 staff throughout their call had only 1 staff member present for most of the visit. These systemic failures placed people at significant risk of avoidable harm and demonstrated a lack of effective governance and oversight.

The seriousness and persistence of these concerns meant the provider was not meeting regulatory requirements, warranting enforcement action to ensure people’s safety.

Staff told us they felt supported in their role. Staff were recruited safely, relevant pre-employment checks were in place including right to work documentation and appropriate checks to ensure staff were safe to work directly with vulnerable people.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider did not ensure effective infection prevention and control (IPC) measures were in place for people at high risk of infection, including those requiring support with PEG and catheter care. People did not have adequate infection prevention guidance within their care records to ensure risks were managed safely. For example, risk mitigation for a person with a PEG in situ did not contain sufficient information for staff to follow, including how to monitor for signs of localised site infection or the actions staff should take if changes were identified. Guidance on the correct cleaning and drying procedures for enteral syringes was not included, nor were instructions for ensuring syringes were disposed of and replaced every seven days.

Although staff had completed IPC training, and people confirmed PPE was worn during personal care, the lack of clear, person‑specific infection prevention guidance meant risks were not consistently managed in line with best practice.

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

The provider did not ensure the safe management of medicines, and systems for medicines optimisation were inadequate. Staff did not have sufficient guidance within the provider’s eMAR (electronic medicine administration record) system, and essential pharmacy instructions were missing from people’s records. For example, information was not included to advise staff whether medicines should be administered with food, before food, or after food to ensure their effectiveness and prevent harm. One person who required support with medicine administration did not receive a prescribed medicine between 17 November 2025 and 26 November 2025, resulting in 10 missed doses.

The provider did not have effective auditing systems or processes in place to identify medicine errors or respond to incidents in a timely manner. Auditing systems had not been consistently completed by the management team, and concerns identified during this inspection had not been recognised or acted upon. This lack of oversight contributed to ineffective medicines management and placed people at significant risk of avoidable harm.

Staff had received training in medicines administration; however, ineffective competency assessments, and our findings at this inspection, meant the registered manager could not be assured staff were competent or confident to carry out this task safely.