Homecare Solutions For You

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated Inadequate.

Inadequate: This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was no effective governance framework in place. The provider did not have an action plan or improvement plan to manage improvements and areas of development; The provider produced an action plan template during our assessment, but this did not contain any of the findings, including those identified through this assessment. The nominated individual and registered manager told us management meetings took place regularly, but no minutes were kept limiting accountability and evidence of decision -making or follow-up actions.

We reviewed audits over the previous 3 months and found these had not identified the areas of concern that we found during our inspection. Key audits such as care plans and infection control audits, were not being completed despite being listed as being in place on the service's Registration Report, Planning and Evidence Record (dated 23/February 2025). Audit tools lacked sufficient detail to support effective oversight.

The statement of purpose contained limited information some of which was inaccurate. This included references to a care coordinator role that had never existed. It was undated and had no review schedule. The business continuity plan referred to a previous director, indicating information had not been kept up to date.

Overall, governance systems were not effective, and required policies, audits and action planning processes were not implemented or followed in practice.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There were significant concerns regarding leadership capability, governance and oversight. Safe recruitment processes were not always followed, with staff files showing missing applications, incomplete interview records, unexplored employment gaps and unverified references. Some recruitment and disciplinary documents had been completed by a former director who was not evidenced as employed by the organisation and had no contract or verified references, creating a conflict of interest and breaching the provider's own policies.

There was ineffective oversight of the organisation’s sponsorship licence. Governance records showed discrepancies in responsibilities and timelines. Although sponsorship approval was granted in November 2025, the provider reported taking over the service in May 2024, indicating a prolonged period where staff were employed under sponsorship arrangements without a valid licence. No evidence was provided during this assessment to demonstrate compliance with Home Office requirements.

Management oversight processes were not adequate. Spot checks were completed, but audits- including those reviewing care records, were not carried out or were ineffective. Where audits were completed, they failed to identify the issues found during this assessment. The registered manager told us they would be de-registering following the assessment.

Overall, leaders did not demonstrate the capacity or insight required to ensure safe, well- governed and compliant care.

People did not always feel they could speak up and that their voice would be heard.

The service had whistleblowing and Freedom to speak up policies, however, these referred to roles that were not in post, such as 'deputy manager'. We were also concerned that the nominated individual acted as the Freedom to Speak Up champion, which may not promote independent or impartial reporting. Not all of the staff we spoke with were familiar with the term 'Freedom to Speak up'.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was no staff working under flexible working arrangements and we found no evidence that flexible working was discussed during recruitment. There were no system or initiatives in place to promote staff wellbeing. Staff had completed equality and diversity training and told us they felt supported, raising no concerns about how they were treated.

The staff handbook did not contain information of support for employees on sponsorship visas.

We saw evidence of regular supervisions and team meetings.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

There were significant governance failings relating to the management of the provider's sponsorship licence and leadership roles. Although the provider took over the service in May 2024, sponsorship approval was not granted until 14 November 2025, resulting in a 18-month period in which the provider did not hold a valid licence despite employing sponsored staff. Governance records did not demonstrate how sponsorship responsibilities were managed or monitored during this time. There was no evidence of oversight, verification or compliance with Home Office requirements, indicating ineffective systems for managing regulatory obligations and identifying risk.

This assessment found widespread and significant shortfalls across the service. We identified breaches relating to safe care and treatment, consent, dignity, staffing and good governance. These failures placed people at risk of not receiving planned care and exposed them to risk of avoidable harm.

The business continuity plan contained inconsistent staffing numbers, contained incomplete sections, listed a previous director as a lead person however this person could not be evidenced

to be working for the service. Action logs were blank, and key risks such as loss of sponsorship were not addressed.

There were shortfalls in incident and accident management, with records not consistently completed correctly, reviewed or followed up, this had not been identified through any provider audits. Complaints were not always manged in line with the provider's own policy.

Quality assurance systems were inadequate. Medicines audits were not robust and had failed to identify issues with administration timings, recording errors, missing PRN protocols, poor daily notes, or gaps and inaccuracies in care plans and risk assessments.

There was a lack of effective understanding and application of the Mental Capacity Act (MCA, 2005). MCA assessments had been completed for all people, including those without capacity concerns, indicating a blanket approach. For one person who did require an MCA assessment, it was incomplete and not decision specific, and no best interest decision had been documented. This had not been identified through any provider audits.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Evidence showed partnership working with GPs, social services and nurse practitioners: however, this was overshadowed by wider governance issues that impact the service's ability to maintain safe and effective collaboration.

Policies reviewed did not consistently contain accurate or up-to-date information. There was no action plan or service improvement plan prior to this assessment, the plan produced during this assessment lacked meaningful actions. The service improvement plan referenced job roles that do not exist within the organisation, for example care coordinator, HR, a concern we previously raised with the provider in relation to other policy documents.

Partner feedback highlighted concerns regarding the professional integrity and overall competency of the Senior Leadership Team, raising questions about the reliability of governance processes that underpin effective partnership working.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There was no effective quality assurance system in place. Although an action plan had been created, it was blank and did not outline responsibilities, timescales or monitoring arrangements. There was no staff reward or recognition scheme, and although managers told us that management meetings took place regularly, there was no minutes recorded to demonstrate learning or actions.

The management team did not consistently contribute to safe or effective practice, nor did they monitor this through robust governance. Whilst they were open and receptive during this assessment and acknowledged gaps in care planning and auditing, these issues had not been identified or addressed prior to this assessment.

The provider did not monitor performance effectively, there was limited focus on continuous learning, innovation or improvement. Policies and procedures did not always contain accurate or up to date information. Despite our findings, people and their relatives spoke positively about the support they received.

Quality assurance systems lacked the oversight needed to support sustainable improvement. Medicines audits completed in October, November and December 2025 failed to identify key issues, including the absence of PRN protocols. Oversight of systems to support learning and improvement had not driven meaningful or sustained change.

Although the provider reported taking action in response to the findings during this assessment, further work was required to ensure these actions were embedded and led to consistent, long-term improvement across the service.