Walfinch Reigate & Horsham

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 provider was in breach of legal regulations in relation to people’s safe care and treatment and informing CQC of notifiable incidents.

This service scored 47 (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.

Accidents and incidents were not proactively learnt from to prevent reoccurrence. For example, we identified an incident in which staff had used unsafe moving and handling techniques to transfer a person from the floor to the sofa following a fall in July 2025. Lessons from this incident were not identified until we informed the managing director during our assessment, and we had also not received the required statutory notification from the provider. Although the staff member involved no longer worked at the service, the provider had not immediately placed the staff member on refresher training for moving and handling. Therefore, provider could not ensure other people had not been put at risk through improper moving and handling during the rest of their time working at the service. Furthermore, there was a missed opportunity to ensure the lessons learnt from this incident were communicated to other staff members to ensure correct moving and handling procedures were always followed. The compliance manager told us communications from lessons learnt, “can be done during team meetings or on a 1:1 basis, it depends on the incident. If it’s something procedural, then it would be a direct supervision or 1:1.” However, this had not occurred in this situation.

Another incident record identified a person who fell on the stairs and injured themselves. However, the accident and incident record did not state what injury was sustained. While the accident and incident log stated there was a review of the care plan and falls risk assessment, there was no evidence that further consideration was given to whether a referral to the occupational therapist was needed to prevent recurrence. CQC had also not received the required statutory notification for this incident. This meant people were at continued risk of receiving poor care.

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.

The managing director told us, “It depends on the severity of the condition, but carers always keep an eye on people. They would check they’re not just tired from a bad night’s sleep. We’re always keeping an eye out for urine infections as they are common. Staff will inform us if people are unwell, and they report it on Birdie (the provider’s electronic recording system) too. From there, we’ll decide if it needs to be communicated to the family, GP or 111.” However, we identified an incident in 2025 where a staff member had delayed contacting emergency services when a person had sustained a head injury. Therefore, this placed the person at risk of not receiving the medical care they required in a timely manner.

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’s safeguarding log contained only one entry for 2025. Records on this concern demonstrated that appropriate action had been taken to ensure people were safeguarded from poor-quality and unsafe care. However, the management team had not identified that poor moving and handling procedures were a safeguarding concern that should be reported and appropriate action taken to safeguard people from avoidable harm.

Despite this, staff felt confident in their responsibilities to safeguard people from harm. One staff member told us, “People are safeguarded from abuse. When I notice a client is not comfortable with a particular person around them or if I see any physical marks on their body, or verbal abuse, or financial abuse l will inform my line manager immediately.” Another staff member told us, “I keep an eye on the client’s body for any signs of abuse and if I notice any changes in how they are behaving.”

The managing director told us, “It’s something that training needs to be completed before they carry out any care calls. We need to make sure they’re aware of the different types of safeguarding there are too. We do the online and face to face training, and we do shadowing too when they first start with us, so its within that whole process. That’s a standard.”

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.

Risks to people were not always appropriately recorded in their care plans. One person’s care plan stated that staff should record their urinary output. However, their care records did not demonstrate this was being done. When we fed this back to the managing director, they told us, “[Person] used to have a catheter, so we used to measure urinary output. You’ve flagged that needs to be reviewed and that task taken out.” Therefore, care plans were not reflective of people’s current needs.

Care plans also did not include details on how to support people with fluctuating needs. For example, one person’s care plan stated they needed different mobility aids and support depending on whether they were experiencing symptoms of their health condition. However, the care plan did not provide details of what mobility aids and what level of support would be provided, depending on whether they were symptomatic. This could result in staff not knowing how to safely support the person on any given day. When we raised this with the managing director, they said, “That makes sense that we need to include that information.” However, the updated care plan we received following our assessment still did not include this information.

Other elements of risk management within care plans were thorough. One person was known to display anxiety and frustration. There were details of how these would present in the person and how staff should support the person through this.

There was also detailed personalised emergency evacuation plans (PEEPs) in people’s care plans on how to support them to leave their home in the event of an emergency, such as a fire.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Risk assessments were undertaken for the environment to identify any hazards. People’s care plans included risk assessments around their home environment. These identified any potential risks in the property, such as trip hazards or animals.

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 ensure staff were appropriately trained to meet people’s needs. Weidentifiedthat one carer was recruited into the agency and only received a 10-hour shadow shift rather than a full induction before providing live-incare to a person. Their training certificates were from another service they had previously worked for. Therefore, the provider had not ensured the staff member had completed training within their organisation.This was despite the compliance manager telling us, “Training was done the week before. After the shadowing and training,there is a competency test.”

In addition, we identified 3 carers who supported a person with Parkinson’s. All 3 care staff had not received training on this condition. This left the person at risk of receiving care that was not effective for their needs.

The provider did not ensure issues with staff performance were followed up effectively or in a timely manner. A supervision record for one staff member stated they ‘nodded off’ during a care call. The registered manager at the time had concluded from the conversation alone that it was a one off and no further action was taken. This had not ensured there were no ongoing performance issues with the staff member that could jeopardise people’s safety. The compliance manager informed us a follow up spot check observation was carried out. However, this was completed 3 months after the incident took place. Therefore, the provider could not be assured that any performance or safety issues had been appropriately addressed and resolved.

Staff were working long shifts without adequate breaks within the day. We identified that one staff member had worked 10 and a half hours without a substantial break in their day. Another staff member had repeatedly worked over 7 hours without a substantial break. The managing director told us, “[Staff member] requested to work on weekends only and requested long hours to fit in all her working hours in fewer days.” However, as an employer, the provider must ensure staff are taking adequate breaks within their working days to ensure they do not tire rapidly and, as a result, provide lower standards of care.

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’s policy stated staff should “have clean, short fingernails which are free from nail products including artificial nails.” However, people fed back to us that some carers did not follow this. One person told us, “[Some carers] are very immature and they do not understand that having long nails with nail varnish isn’t good. I do not approve of it.” Long nails and varnish increase the accumulation of bacteria, making it difficult to disinfect hands thoroughly. This can lead to an increased risk of infection transmission to people, especially those with underlying health conditions. The managing director told us, “That has been flagged and discussed in supervisions. We try and drum it into them. They’ll be spot checked again soon after that to make sure they’re toeing the line so to speak.”

The person went on to tell us staff “don’t wear aprons. They could wear gloves depending on the task they are doing.” This was despite them receiving support with their personal care and hygiene. This could again lead to the transmission of infections due to poor infection prevention and control (IPC) practices. Another person told us, “When they don’t [wear aprons or gloves], I never have them back.” The managing director told us, “We have a full stock of PPE (personal protective equipment) here. When staff conduct their training, they’re given supplies. We ask the carers to let us know when they are running low and use the opportunity to drop PPE to them and do a spot check or quality check with the service user at the same time.” However, this had not identified the ongoing issues with poor IPC practices among staff.

However, other people told us the staff members who supported them did wear the correct PPE and they had no concerns.

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.

One person’s care plan stated they were at moderate risk with medicine management due to a ‘complex medicine regime. Carers to prompt and supervise medication administration. Use of a medication tracker or blister pack to avoid dosing errors.’ When we asked the managing director for a copy of this, he stated that the person usually managed their medicine independently but had recently required more support. They stated, “If he freezes, then we will prep his [medicine administration] pen for him and then hand it to him. I can check to see if there is a physical record of this somewhere, and perhaps that is something that I need to change in the care plan.” Therefore, staff were preparing the medicine dosage and were involved in the administration of the medicine. However, there was no medical administration record (MAR) for this. This meant that if there were an overdose or an underdose of the medicine, the provider would not be able to confirm whether the medicine dosage was prepared by the person or a particular staff member.

Protocols for as and when medicines (PRN) were in place for people. These included body maps of where topical creams and gels should be applied on people’s body dependent on their prescription.