Axis Care Group Ltd

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 requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 had a shared vision and strategy, but this was not always being achieved.

The provider had a ‘philosophy of care’ document which included them being dedicated to promoting independence, dignity and respect, supporting personal choice, decision-making and privacy and delivering skilled care to enable optimum health and wellbeing. However, this assessment found people were not always being fully supported to make personal choices and staff were not fully trained to deliver the best care to meet people’s additional needs.

However, staff told us there was a good culture within the service, in which they felt supported by their leaders. A member of staff told us how they were new to the service and emphasised how much support they had in their role prior to completing shifts independently.

The provider had completed a survey for staff which reflected a positive staff culture. Most staff answered that they liked their job, liked their co – workers, felt confident and supported by the team and were happy with their pay.

Although the leaders had the skills, knowledge, experience and credibility to lead effectively, there were key issues which had not been identified by them.

The nominated individual and registered manager had a great amount of experience and knowledge in relation to adult social care and were passionate about their roles. However, they had not established robust governance systems and quality assurance processes to identify issues which we had picked up on during the inspection. The leaders had not fully embedded the principles of ‘Right support, right care and right culture’ as there were improvements needed in how support was delivered and how person centred it was.

The registered manager told us they were responsible for the care plans and risk assessments for all the people being supported. These contained errors which required addressing.

People/relatives we spoke with were complimentary about the nominated individual and registered manager, stating they had met them on various occasions and felt they cared about their progress.

Staff provided positive responses regarding the leadership of the service. Staff felt very well supported within their roles.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. However, the provider’s staff handbook required amendments to be made to ensure staff felt more empowered to do so.

Staff told us they felt confident they would speak up, if they had any concerns. They felt well supported by their manager and nominated individual and were confident they would listen if they were to speak to them. They were aware of the CQC’s role and how to contact us.

The provider had a ‘raising concerns, freedom to speak up’ policy which contained the appropriate details with relevant contact details within it.

However, the provider’s freedom to speak up procedure within their staff handbook heavily emphasised disciplinary consequences, criminal liability, investigatory and disciplinary hearings, and there was much less on support for staff, reassurance and psychological safety. This could potentially discourage staff from speaking up, even if they were acting in good faith. The procedure only names 2 leaders and does not offer any suggestions if the concerns were raised about them or if they were unavailable for a long period. There is also limited detail regarding feedback to the whistle-blower, how investigations are conducted and how records are kept which undermines confidence in the process.

The grievance procedure within the staff handbook states staff should contact human resources if they are dissatisfied with any matter relating to their employment, however, no contact details were included do so.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had an equality, diversity and inclusion policy in place, and this was reviewed regularly, and was up to date at the time of the inspection.

Staff completed training on equality, diversity and inclusion. All staff were compliant with this training at the time of the inspection.

However, we did not see evidence of staff contracts and the working hours for staff was complicated by the rota which did not clearly indicate the hours worked. We could not be assured staff were not working excessive hours, or not enough hours due to this lack of evidence.

The provider did not have robust governance systems and processes or oversight of risks, performance and outcomes.

The provider did not implement relevant or mandatory quality frameworks, recognised standards, best practices or equivalents to improve equity in experience and outcomes for people using services and tackle known inequalities. For example, the provider had not ensured they fully implemented the REACH standards and ‘Right support, right care, right culture principles.’

The provider completed six-monthly audits to review support plans; however, these audits did not identify several key issues identified during this inspection. For example, despite medicines audits being in place we found a wealth of issues regarding medicines which needed to be improved. This indicated that governance and quality assurance processes required strengthening to ensure they are effective in identifying and addressing areas for improvement.

Despite requests, the provider did not supply their governance and audit policies. As a result, we could not be assured that there was a clear audit schedule in place or that the provider was operating in line with its own policy requirements. We also did not see evidence of regular audits in relation to staff recruitment, training compliance, supervision, or appraisal processes, which limited oversight of these key areas.

Daily notes were subject to audit; however, these audits had not identified inconsistencies between recorded care and the requirements set out in risk assessments. For example, one person required repositioning every two hours while asleep, and although this was specified in their risk assessment, daily notes did not evidence that this had consistently been documented. In addition, food charts did not align with information recorded in daily notes for the same individual, and oral hygiene care, including attempts to provide this, was not consistently recorded. This indicated that audit processes had not been effective in identifying gaps in recording. Leaders did not have sufficient oversight to ensure staff were completing records accurately and consistently, particularly for individuals at risk of malnutrition, dehydration, and those requiring support with oral hygiene.

The provider was unable to evidence that regular, minuted meetings had taken place with people or their representatives in relation to their care. Given that individuals had only recently moved into the service, we would have expected more frequent engagement and documented communication with people, their representatives, and relevant professionals to ensure care remained appropriate and responsive to their needs.

Staff told us they attended monthly staff meetings, which were held jointly with domiciliary care staff and leaders, and reported these to be helpful. However, a review of the minutes from the December 2025 meeting showed that there was no discussion relating to the supported living service. Given that people had only recently moved into the service at that time, we would have expected specific discussion and oversight of this provision within these meetings.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Partners of the service told us they felt communication was good with the service and they were made aware of any safety events.

A professional working with the service stated, “Axis Care works collaboratively with partners through joint reviews, shared action planning, and responsive communication.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

The provider had completed an external audit in November 2025. This identified various issues including staff recruitment records, staff having not completed the appropriate autism and learning disabilities training and risk assessments and care plans lacking in accuracy and some not being in place. The provider had implemented an action plan which included details of how they will address the issues identified. The action plan indicated actions for the next quarter and for the next year based on the findings. Although the actions met the points raised within the audit, we would have expected swifter action to have been taken for some of the critical findings, including risk assessments not being in place.

The provider’s governance systems had failed to identify recurring issues. Furthermore, there is an absence of systems in place to ensure appropriate oversight of risks or shortfalls, as emphasised during this report.