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 61 (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, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had a ‘philosophy of care’ document which described how they were dedicated to promoting independence, dignity and respect, supporting personal choice, decision-making and privacy and delivering skilled care to enable optimum health and wellbeing.

The provider also had standards of care which were outlined in the service user guide. These were in line with CQC’s 5 key questions.

Staff told us there was a positive culture and a culture of learning rather than blame. A staff member told us the registered manager had instilled within staff that mistakes would happen, but to be transparent and open about them for the service to learn and grow.

Leaders expressed how they still emphasised good team working and mutual support, despite staff working mainly independently or in partnerships in the community. They did this by ensuring regular team meetings were taking place.

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 were experienced and knowledgeable about 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 registered manager told us they were responsible for the care plans and risk assessments for all the people being supported. These contained significant gaps which required addressing.

Most people and relatives we spoke with were complimentary about the leaders of the service. For example, a relative said, “I feel like we have known them forever, they are down to earth people and always say let us know if we can help.” A person receiving care said “[The registered manager] visits once a month and always asks are there any problems and if there are [they] sort them out.”

Staff were positive about the leadership at the service. A staff member said, “The management are great, the managers are very responsive and they always help. They always provide a listening ear and provide helpful feedback for us all.”

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 less information about support for staff, reassurance and psychological safety. This could potentially discourage staff from speaking up, even if they were acting in good faith.

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.

Staff told us leaders offered flexible working and emergency paid leave when required. Leaders told us they made reasonable adjustments for staff if they had appointments or if they needed to reduce their hours.

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

People’s care plans contained errors, including incomplete sentences, which reduced their clarity and professionalism. Care plans did not consistently reflect identified risks, and some risks had not been formally risk assessed. This demonstrated insufficient oversight of the care planning process and increased the risk of inconsistent or unsafe care delivery.

The provider used a risk rating system based on severity; however, this required review. For example, risks associated with hair care were rated as high, despite this task being undertaken by family members, while the application of creams was rated as medium, despite the person having pressure sores. This indicated that risk ratings were not always proportionate to the level of clinical risk, which could result in staff prioritising tasks inappropriately and potentially overlooking higher-risk concerns.

The provider’s governance systems and oversight required strengthening. We requested the provider’s safeguarding log and examples of recent safeguarding incidents. The safeguarding log was not provided, which meant we could not verify whether statutory notifications had been submitted to CQC appropriately.

Recruitment processes, as referenced under safe and effective staffing, contained omissions which further demonstrated weaknesses in oversight. Although the provider maintained an appraisal tracker, dates did not consistently align with the appraisal documents reviewed. Similarly, the registered manager’s appraisal date differed between the tracker and the appraisal record. Inaccurate records reduce assurance that staff performance is monitored effectively. In addition, where staff had completed refresher training, such as medicines management, this was not consistently updated on the mandatory training log.

The provider was asked to send evidence of audits for the last 3 months. We were sent a yearly audit tracker which outlined the audits, their findings and actions required and not the actual audits themselves. Some findings were generic and did not clearly identify specific issues. For example, a January 2026 staff spot check audit listed as a finding that “staff supervision and appraisal compliance should be recorded and tracked regularly,” which was an action rather than a finding. The audit summary did not specify how many spot checks had been undertaken, what themes had been identified, or what improvements were required. Similarly, a six-monthly audit of daily notes described the audit process but did not evidence how many records were reviewed, what issues were identified, or what action had been taken. Without detailed audit evidence, the provider could not demonstrate effective quality monitoring or continuous improvement.

Some audit actions contradicted information shared during the inspection. For example, one action stated that care planning refresher training would be completed by staff. However, we were informed that only the registered manager completed and updated care plans. In addition, a training audit recorded all staff training as up to date, despite the provider acknowledging, following an external audit, that advanced autism and learning disability training remained outstanding. These inconsistencies further reduced assurance in the accuracy of governance systems.

The provider’s statement of purpose contained inaccuracies. In addition, the registered manager’s most recent appraisal referred to them as a deputy manager, a position they had not held. The service user guide also identified the nominated individual as the registered manager. The statement of purpose is a key regulatory document, and inaccuracies within it reduced transparency and clarity regarding who held legal responsibility for the service.

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

The provider sought advice and guidance from healthcare professionals, local experts and agencies including district nurses, social workers, GP’s and occupational therapists.

Leaders of the service engaged with other agencies, including social care services and the local authority for peer to peer support.

The local authority explained they could not provide extensive feedback regarding the provider as they had not carried out quality monitoring with them, however, they stated they had no current safeguarding concerns and engaged well with them.

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

The provider had an external audit completed 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.

In addition to this, the points raised on audits, are a snapshot in time, and although addressing the issues identified would be a positive step, the provider also needed to ensure appropriate governance systems and quality assurance checks were in place which could identify risks and concerns proactively.

However, the provider was open to suggestions of how they could improve the service. During the inspection process, the provider made significant improvements to care plans and risk assessments based on onsite feedback provided.