Utopia Care Limited

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 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 people’s safe care and treatment.
 

This service scored 56 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. For example, we found that where people had made disclosures to staff, staff made kept detailed notes, but the provider did not always investigate, mitigate risk, and share learning with staff and other professionals. However, the provider had processes in place to support learning, including care plan reviews by senior staff and management engagement with people using the service. Feedback from relatives described responsive reviews and timely adjustments by the provider.
A relative told us, "They are very proactive and during reviews, as well as on an ad hoc basis, will recognise any changes that are required and implement them quickly after discussion". Reviews of care plans were evidenced multiple times during March 2026 across the records of the Service Users sampled.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. We could not see any learning from this incident and care plans had not been updated. Emergency critical information, such as the location of a people’s Recommended Summary Plan for Emergency Care and Treatment [ReSPECT] documentation, was not always clearly recorded by the provider.
There was evidence of effective transition in other cases, including timely care planning following hospital discharge and structured onboarding when people transferred from other providers. A service user described a comparable transfer between providers: "When I transferred from a previous care company to Utopia, the manager completed a care plan and risk assessments".
 

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 consistently recognise or escalate safeguarding concerns. Records showed unexplained bruising, disclosure of a dislocated shoulder during a high risk task, and unsafe medicines practice for a person without capacity, without appropriate safeguarding escalation or follow up. Financial safeguarding arrangements were clearly documented but not consistently evidenced in daily records. Deprivation of Liberties Safeguards (Dols) were not always apparent in care plans. People reported feeling safe with their carers. One Service User said, "I feel safe with my carers", and a relative confirmed, "They [Relative] really like them and feel happy and safe with them". The provider had started taking action to address the issues identified during the assessment.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We found events including when people developed a foot wound in and disclosed a dislocated shoulder; did not trigger appropriate care plan reviews, and the skin integrity plan continued to record no skin concerns. We found that where a service user reported a low oxygen saturation reading, however the provider had not conducted a formal incident review, and no system was put in place for continuous monitoring. Service users were involved in the design of their care, but the provider did not consistently adapt risk management to the changing reality of people's health. Service users and relatives reported being involved in initial care planning. One person said, "I was very involved with the care plan and was asked how I would like my care to be delivered". Care plans were written in first-person voice throughout, evidencing co-production.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider used equipment effectively to reduce environmental risk. The provider carried out an environmental risk assessment of people’s homes during the initial assessment, and we could see that these were regularly reviewed. Records showed detailed and safe procedures for complex care tasks, including bathing, mobility and use of assistive equipment. Equipment provision responded to identified needs and professional input. A relative told us; "The company contacted the Occupational Therapist (OT) and [relative] has a hospital bed". We saw that the provider carried out daily and weekly checks, and where people used equipment, statutory checks were carried out

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. They did not always work together well to provide safe care that met people’s individual needs. Mandatory training requirements were not consistently met. The Oliver McGowan Mandatory Training had not been completed by most staff, and other core training modules were incomplete or expired. Documentation quality varied between staff, indicating inconsistent supervision.
People and relatives reported continuity of staffing and trusted relationships. They told us: "They have continuity of care and have 3 different carers that call each week", and "I usually have the same carer for all calls". There was sufficient continuity of carers, but the workforce skill mix was not always consistent.
 

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. Infection prevention and control practice was consistently described as safe and embedded. PPE use, hand hygiene and waste disposal were routinely evidenced in care notes and confirmed by people using the service and their relatives. A person noted: "They use their gloves and aprons and always dispose of the gloves and wash their hands before making me a cup of tea". Care notes evidenced infection control as a documented task at every visit for every person PPE use, glove change between tasks and hand hygiene were embedded into routine practice across the workforce.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We saw that for a person assessed to lack capacity around her medication, that staff had left pain relief medication for the person to take later. For a separate person lacking medication capacity, the system recorded several medicines under "Assist" rather than "Administer", creating a risk that medicines could be left for self-administration. Medicines safety processes required strengthening. Where medicines were administered routinely, people were confident in the process. A relative stated, "They give them [relative] their tablets, and there have never been any errors with their medicine".