Deway Care Limited

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 newly registered 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 regulations in relation to recruitment and safe care and treatment related to risk assessments and medicines management.

This service scored 47 (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 process for incident reporting. Staff were to record any incidents in the person’s daily log, report to the office and fill in an incident report. A staff member told us, “I will call coordinator/supervisor tell them what I saw, put in my report.” A person’s relative said, “If they notice anything like if [person] has [injured] themself, they will let me know. “

The provider’s incident tracker included the date, those involved, details of the incident, any action taken and lessons learnt. However, it was unclear how these lessons were shared with staff and people we spoke with described incidents which were not on the provider’s tracker. This meant we were not assured incidents were always recorded as required.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider reviewed new referrals to ensure they could meet people’s needs. Once they had completed their assessment process, if they found the person had additional needs to those they had been asked to support with, they went back to the commissioners to address this.

The provider had a process to manage safeguarding concerns. They told us staff were expected to report any concerns to the office, and they would investigate them. They were aware these needed to be reported to the local authority and CQC.

Staff were trained in safeguarding. A staff member described it as “It’s helping or protecting people from harm.”

The provider told us they had no safeguarding concerns at the time of our visit. However, we received information during our inspection which suggested a concern had been raised. Following our inspection, the provider told us a safeguarding concern was raised 22 April 2026, this was after our second visit so would not be among the information we reviewed. We would expect a notification to be submitted for this but this has not been done. Therefore, we were not assured safeguarding concerns were always recorded and reported as required.

The provider did not always work well with people to manage risks. They had not ensured all risk assessments were completed. We reviewed the records of 2 people who were cared for in bed and neither of them had a bed rails risk assessment or guidance for staff in the event they needed to evacuate. A person who was diabetic did not have a risk assessment for this.

Where risk assessments were completed, they included clear guidance for staff. For example, for those at risk of pressure injury it stated to ensure people were dried properly, check skin, apply creams and report changes.

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

People’s records did not always include an environment risk assessment. Where they were completed, we saw they included information about utilities, lighting and trip hazards. However, there was no evacuation guidance, and staff had not received fire training. Following our inspection, the provider shared certificates which showed staff had received fire training.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

The provider had not ensured safe recruitment procedures were always followed. We reviewed 5 agency staff profiles and found 1 did not include a disclosure barring service (DBS) reference. These background checks enable services to make sure the people in their care are protected. We fed this back to a manager who obtained the DBS certificate from the agency, dated 1 April 2026. We reviewed staff rotas and found this staff member had been working unsupervised throughout March 2026. This meant the provider were not assured staff were suitable to provide care before starting work.

The provider was reliant on agency staff. This had an impact on the timeliness of people’s visits. People told us staff were not always on time, and they were not informed of changes or delays. A relative said, “[Person] was told [they] would have the same carers, and they would come at the same time. This hasn’t happened.” Another relative told us, “They never come at the same time…they were late by 1½ hours and no phone call to say they were going to be late. They are late practically every day now, but they have never completely missed a visit.”

We fed this back to the registered manager, and they told us recruitment was a challenge, but they had tried to communicate with people to make them aware of this.

Staff received effective support, supervision and development. Staff we spoke with felt their workload was manageable and confirmed they had regular supervision. A staff member said, “If I feel I can’t manage I always talk with care coordinator.”

The provider assessed and managed the risk of infection. They had an infection prevention and control (IPC) policy. Compliance with this was monitored via staff spot checks.

People and relatives we spoke with confirmed staff washed their hands and wore Personal Protective Equipment (PPE) as appropriate. A person told us, “They wear gloves and wash their hands.” Another person’s relative said, “The staff wear gloves and masks and wash their hands.”

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff had not always documented medicines they administered to people correctly. Some people were prescribed PRN medicines, which are those administered as and when required, some of which have variable doses. We found where the doses were variable, staff had not recorded the actual amount administered, or why the medicine was given and whether it had been effective. Where other PRN medicines were available but not administered, there was no evidence in medicines records to show these were offered. This meant people were at risk of both being administered more PRN than needed and not offered what was required.

The provider had not completed PRN protocols. This meant there was no information to guide staff in when to administer these medicines.

Staff were assessed as competent in administering medicines with no areas for improvement identified in those we reviewed. However, we found not all staff we spoke with understood what PRN medicines were and when they should be administered.