Axis Care Group Ltd

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 staff recruitment processes at the service.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders needed to ensure the processes around investigating safety events was strengthened. However, staff felt there was a proactive and positive culture of safety based on openness and honesty. Lessons were often learnt to continually identify and embed good practice.

The reporting of incidents and the managerial process around incident reviews needed better oversight as there were some inaccuracies regarding the documentation.

However, we did see examples of incidents which had appropriately escalated, and concerns had been raised with the relevant relatives or professionals.

Staff were aware of their responsibilities to complete accident and incident forms and understood the importance of contacting their seniors when these occurred. Staff, people and relatives told us they felt confident raising concerns, and there was evidence of lessons being learned from incidents.

The provider did not always make sure transitions were smooth when people moved between different services.

There was a mixed response from people and relatives relating to their transition into the service. Some felt the transition was smooth, one relative said “It (the transition) was very good, all information was given to myself about what was arranged at the hospital and my [relatives] care was there within the hour of [them] getting back home.” In contrast, some felt the initial settling in phase could have been improved, one relative said, “It wasn’t perfect…There was a language barrier initially.” A person receiving care from the service said, “At first the care was not very good, and I was not impressed by them, however after raising these concerns with the registered manager the care, over time improved.”

Due to issues with care plans and risk assessments not always being up to date, we were not assured the service the person was being transitioned to would have a strong awareness of the risks to people across their care journeys.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

The provider had a safeguarding adult’s policy and procedure which was last reviewed in 2026. This contained all the appropriate details and had specific contact details for the local authorities. The provider did not provide evidence of a safeguarding children policy. This is essential, as it ensures that any potential concerns involving children.

Staff did receive training on safeguarding children and safeguarding adults. All staff were fully compliant with this training.

Staff had good knowledge of what constituted a safeguarding concern and knew how to raise safeguarding concerns to their leaders.

People and their relatives felt they or their loved ones were safe in the providers care and all felt comfortable they could raise concerns. A relative said, “I do feel my [relative] is safe, I feel (if I had) any concerns regarding neglect or abuse, I know I can speak out and would do so.”

There was some governance issues identified regarding safeguarding which needed addressing. These have been documented under the governance, management and sustainability quality statement.

The provider did not work well with people to understand and manage risks.

We requested evidence of escalation procedures and protocols; however, these were not provided. These included procedures relating to urgent clinical needs or care deterioration, such as missed medication, pressure damage, and unsafe moving and handling.

The provider did not consistently ensure risks were appropriately assessed or clearly documented. For example, one person with a history of falls did not have a falls risk assessment in place. Another person’s assessment identified a risk of dysphagia (a condition in which people have difficulty swallowing food, liquids or saliva), but no corresponding risk assessment was completed. A further person was recorded as having type 1 diabetes; however, there was no specific risk assessment or care plan detail outlining associated risks, including hypoglycaemia or hyperglycaemia. The same person had a diagnosis of dementia which was not reflected within their care plan or risk assessments. Their infection risk assessment referenced a urine infection and blood identified in a catheter by a district nurse, but this was not recorded elsewhere within the care plan or other risk assessments. Additionally, contradictory information was noted within the continence risk assessment.

Staff and leaders did not always complete risk assessments thoroughly. For example, one person assessed as high risk of pressure sores, and who had two existing pressure sores, had guidance recorded as “apply barrier cream, monitor and report concerns,” which lacked clear direction. The same person’s care plan did not document urinary or faecal incontinence, nor did it reflect identified sight impairment.

Some risk assessments contained inconsistencies or errors. For example, a nutrition and hydration assessment recorded conflicting information regarding urinary tract infection risk. Another person’s wellbeing assessment stated their relative was responsible for medication management, which was inconsistent with the care plan that outlined shared responsibility between family and staff. In the same case, the skin integrity care plan indicated repositioning was in place, but no supporting detail was documented.

Care plans did not always reflect identified risks. For example, one person’s risk assessment documented pressure sores which were not referenced in the care plan. Required catheter care support was also not included. Another person’s history of skin issues and need for regular repositioning were identified in risk assessments but not consistently reflected in care planning documentation.

The provider did not consistently record where ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) decisions were located, which meant staff may not have been able to access this information promptly in an emergency.

Following the inspection, the provider demonstrated significant improvements to care plans and risk assessments reviewed, evidencing that feedback had been acted upon and improvements implemented.

The provider did not always detect and control potential risks in the care environment. They did not always make sure personal evacuation emergency plans were personalised.

The provider ensured fire risk assessments were completed for all people who used the service. However, the fire risk assessment for some people had identified risks including an item being combustible near the cooker and the “service user regularly applying emollient creams” with no risk controls documented.

People had personal evacuation emergency plans (PEEPS) in place in the event of a fire. However, PEEPS were not always personalised. For example, one person’s PEEP contained generic sentences, such as “For those unable to be supported to leave” and “If there are lift’s, they are not to be used.” The PEEP also identified key equipment such as the gas supply and mains fuse box but did not identify where these were located.

Following the onsite inspection, the provider sent some evidence of safety checks which had been completed for the office situated in Leigh. The electrical installation condition report had been completed following the onsite inspection and had last been completed in 2021. The provider had also had a fire risk assessment, gas safety assessment and an assessment of legionella risks completed by external companies following the inspection. However, the provider did not send any evidence of display screen equipment risk assessments for office- staff. Therefore, we could not be assured all potential risks had been identified and mitigated.

The provider did not always make sure staff completed all mandatory training. They did not ensure all appropriate documents were observed/stored when staff were recruited.

The provider maintained a training matrix which indicated high overall compliance. However, they did not evidence completion of advanced autism and learning disability training, despite being registered to support people with these needs. We requested evidence of external training completion, including moving and handling and catheter care, but this was not provided.

Recruitment records were not consistently complete. Some staff files did not contain proof of identification, proof of address or contracts of employment. A staff member had started within their role before they had received their DBS (disclosure and barring service) certificate (this indicates whether people have criminal convictions and should be checked prior to staff starting in their roles. Interviews were sometimes conducted by a single staff member rather than two, and in some cases by staff who were not in senior positions. We were not provided with evidence that probationary performance reviews had been completed before staff began working independently.

The provider submitted evidence of appraisals for one care coordinator and two care staff. The two care staff appraisals were identical in content, with only the dates differing, which called into question their accuracy and credibility.

Call log data for January 2026, showed a quarter of calls commenced were more than 15 minutes late, with a minority being more than 45 minutes late. Leaders told us the call data was due to poor signal in the location the people were supported, and they were looking at ways to address this.

Staff told us there were sufficient staffing levels and that cover was available when colleagues were absent. Most people and relatives reported that care workers arrived on time and remained for the allocated duration.

The provider evidenced that spot checks were undertaken. These unannounced visits were carried out by a manager or senior staff member to monitor practice and ensure care was delivered appropriately. The records reviewed did not identify significant concerns.

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.

Staff had access to Personal Protective Equipment (PPE) at the point of care. Records showed staff were trained in infection, prevention and control. People told us staff wore PPE and supported them to clean their homes.

Medicine administration records (MARs) showed on the whole people received their medicines as prescribed. However, information recorded on the MARs was not always sufficient to ensure the possible risks with administration were mitigated.

The MAR charts showed that time sensitive medicines were not always administered as prescribed.

The provider ensured people had written plans in place which provided information about how people were supported to take medication on an as required basis (PRN).

The support people needed in relation to medicines was clearly documented and specific to each person.

Staff that administered medicines had completed safe management of medicines training and had undergone an assessment to check their competency to administer medicines safely.

Audits were being carried out on a regular basis but were not robust enough to identify some of the issues identified during the assessment.