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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

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 Inadequate.

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.

This service scored 38 (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.

Care plans lacked information to guide staff practice for example, diabetes care plans did not contain guidance for hypoglycaemia or hyperglycaemia such as signs to look out for and actions to take. This was discussed with the registered manager at the time of the assessment, and the management team told us this was available within the person’s home, however they would add to their care plan.

There was a lack of oversight of incidents and accidents with no evidence that these were reviewed, investigated or used to drive improvements. Incident records did not match daily care notes, and provider audits failed to identify these discrepancies. Despite agreeing to investigate incidents during this assessment, the management team did not provide any details of their investigations, actions or the findings.

There was no effective action planning. The provider told us during this assessment they would implement an action plan. However, only a blank template was shared with us and none of the risks or concerns we had identified during this assessment had been added to show any actions taken or planned.

The provider did not demonstrate learning from complaints. We requested investigation records for repeated raised concerns about one person’s care; however, this was not provided. A complaint raised had resulted in staff and family meetings the following day, yet the provider did not follow their own complaints policy to investigate and respond to the concerns raised.

Staffing management lacked oversight. We reviewed records of a disciplinary matter and found significant gaps in the documentation and that the provider’s policies had not been followed. Additionally, a staff member involved in managing confidential paperwork had no employment contract on file, this demonstrated further governance failures.

The service failed to recognise, investigate or learn from incidents or complaints. Opportunities to improve safety were missed, and repeated failings placed people at ongoing risk of harm.

The provider did not always maintain safe systems of care, to manage risks people could experience or be exposed to.

People’s needs were assessed before they started using the service. These assessments did not always evidence that people had consented to family members involvement with their care planning and support, however family members were involved in people’s care and the planning of their care. Future planning was also not considered within the pre assessments, this meant people’s future care and support preferences were not fully explored, understood or prepared for increasing the risk that their longer-term needs, wishes would not be in cooperated into safe and effective planning and delivery of care. This was discussed with the provider’s management team who told us they would action this going forward. One person told us,” The manager came to go over what I needed and completed my care plan with me”.

Care plans for people requiring urinary catheter care did not contain sufficient detail to guide staff practice safely. However, people told us that staff were very aware of what to watch for to avoid complications. and staff displayed knowledge in this area.

There were insufficient processes in place to monitor and audit safeguarding practices, and incidents were not consistently reviewed to identify potential safeguarding concerns. Although policies for safeguarding, whistleblowing and mental capacity were in place, they were not always followed. The provider did not always presume people had capacity unless concerns were identified. This meant people’s rights and autonomy were not promoted. Staff had completed safeguarding training. Oversight and recording of actions and lessons learnt were limited, though the registered manager was able to describe learning verbally.

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.

Risk assessments were not consistently completed, reviewed or maintained to ensure people were fully supported to manage risks safely. Although some risk assessments were in place, several were missing, including assessments of risks for the use of flammable creams, smoking, anticoagulant medication and equipment. Daily care records were not routinely reviewed, meaning emerging risks were not always identified or mitigated.

One person's care plan instructed two staff members support the person by one staff member walking in front of the person and one staff behind when using the stairs and to manually guide the person's right foot if it became stuck. Care notes confirmed this practice. There had been no occupational therapist (OT) or appropriate risk assessment to guide this intervention leaving the person and staff at risk of injury.

Information shared suggested family supported with the stairs, but this was not evidenced within care plans, care notes or risk documentation. This was discussed during this assessment, and the management team told us they would do a full care review.

Another person received support with eating and drinking, yet no assessment from the Speech and Language Team (SALT) had taken place and no robust risk assessment was in place to assess the risks such as choking or aspiration. This exposed the person to potential harm, as staff lacked necessary guidance to ensure safe eating and drinking support. The service had received a complaint regarding a member of staff which included concerns about the support provided to a person with eating.

Risk management plans for people were either absent or ineffective, lacking necessary guidance for staff to mitigate associated risks. During this assessment, the management team began creating missing risk assessments: however, one example presented to us contained inaccurate information, referencing a sling that was neither required nor used which meant the risk assessment did not reflect the person’s actual needs, creating a risk of potential unsafe or inappropriate care.

Despite the issues we identified, people and their relatives told us they felt able to contact the service when needed. One person told us,” We have as much contact we need with the manager but at least once a month she or someone from the office rings us up to see if we are ok”.

The provider did not always detect and control potential risks in the care environment.

Environmental risk assessments (RA) were in place but required improvement. Risk assessment did not clearly identify who was responsible for routinely testing smoke alarms or evidence advice provided or actions taken, such as referrals to the fire service or recommendations to maintain a first aid box.

Despite these gaps, people and relatives felt their environment was managed safely. One family member told us, “Measures have been put in place to make sure she is safe in the house, and the carers make sure that when they leave there are no obstacles are in (relatives)way”.

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.

There were significant concerns identified regarding safe recruitment, staff oversight and the organisation's management of its sponsorship licence. Governance records showed discrepancies in the timeline and responsibilities relating to sponsorship duties. Although sponsorship was granted 14 November 2025, the provider reported taking over the service in May 2024. This indicates an 18- month period where the provider did not hold a valid licence despite staff being employed under sponsorship arrangements. We were not shown records that demonstrated adequate oversight, verification or compliance with Home Office requirements, indicating ineffective governance of statutory obligations.

Safe recruitment processes were not always followed. Some staff files showed missing application forms, incomplete interview documentation, gaps in employment that had not been identified or explored and unverified references. In some cases, recruitment documents and disciplinary records had been completed by a former director, who was not evidenced as being employed by the company as an employee or consultant. The provider told us the former director continued to act as an consultant but there was no contract or appropriate references for this individual, creating a clear conflict of interest and breaching the provider's own recruitment policy.

A disciplinary case reviewed showed no clear evidence of a formal warning process being followed .and paperwork was incomplete. Both the nominated individual and registered manger demonstrated limited understanding of appropriate human resource procedures.

Training records lacked consistency. Staff had only recently completed face to face manual handling and basic life support training, and no evidence was received of any previous face to face training despite our repeated requests for this information. In addition, staff competencies had not been consistently assessed before supporting people with medicines.

These combined failings demonstrate that staffing was not managed safely or effectively, with significant risks arising from unsafe recruitment, inadequate training oversight, weak governance and ineffective leadership controls.

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 service had an infection prevention and control (IPC) policy in place and staff had received IPC training, Personal protective equipment (PPE) was available for staff to collect from the office when required or during team meetings, however this collection time or travel was not paid meaning staff had to do this in their own time.

Oversight of IPC practice required improvement. Spot checks and observations did not consistently evidence staff were consistently adhering to required standards, including wearing appropriate clothing, being bare below elbows, and avoiding nail varnish or excessive jewellery when delivering personal care. The registered manager acknowledged these gaps and confirmed this would be added to their monitoring records.

Care plans required greater consistently to clearly identify the level of personal care support required by each person. Limited oversight of IPC compliance meant the service could not be assured that infection control measures were consistently applied in 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 planning their care in relation to medicines.

There were significant shortfalls in the management of medicines, placing people at risk of harm. Electronic Medication Administration Records (EMAR) were inconsistent, with gaps in recording, and medicines not consistently listed on care plans despite care notes indicated they had been administered.

EMAR did not consistently evidence medicine administration, and although management told us that missing entries would be recorded on paper forms, these were not provided despite requests. Where EMAR indicated medicines had run out, there was no evidence of actions taken to source further medicines or to seek medical advice.

Management did not demonstrate effective oversight to ensure people consistently received their medicines as prescribed.

People did not have 'as required' (PRN) protocols in place, this was discussed during this assessment, and the management team told us they had started to put these in place where required but it remained inconsistent

People did not always receive adequate spacing between doses of medicines; this created a risk of overdose. This was not identified through provider audits. The management team acknowledged their audits lacked sufficient detail and told us improvements would be made.

People with diabetes care plans did not contain clear guidance on recognising signs of hypo-or hyperglycaemia, when this was discussed with the management team they told us there was a leaflet provided in a folder at the property, but this was not personalised to the person.

Care notes evidenced that family members were dispensing medicines which care staff were administering without any assessment of the risks of this approach or the acknowledgement that this is not considered safe practice. in place.

Staff had received medicines training however we saw evidence of care staff supporting with medicines without having their competencies assessed, further compromising safe practice.

Despite our findings people and their relatives described staff reminding them about medicines and storing them securely. One person told us, "The carers dispense her medication which is kept in a locked cupboard in the kitchen”. Another said “I order the medication but the carer 's always remind me “.