24/7 Divine Healthcare 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 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 safe care and treatment, staffing, fit and proper persons employed, and the ways people’s medicines were managed.

This service scored 56 (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 positive culture of safety. The systems and processes in place to manage accidents and incidents were not effective. For example, the daily care delivery record of a person indicated that there were incidents of distress on most days they received support. However, there was no guidance for care workers about how to report these incidents and manage. There were no incidents and accidents records to show these were discussed to ensure learning was shared.

The provider worked in partnership with health and social care professional bodies to ensure people received appropriate support. For example, when one person experienced a crisis, the provider sought support from relevant professionals to ensure their needs were met.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. One relative told us, “My loved ones are happy and safe with them (Care workers) and I am happy for the service.” The provider had a policy and procedure for safeguarding adults from abuse. Except for one care worker all remaining care workers completed safeguarding training and were aware of the action to take if they suspected someone had been abused including reporting concerns to the nominated individual (NI). The NI told us that there had been no safeguarding incident since their registration in 2023.

The provider did not work well with people to understand and manage risks. For example, one person for whom the local authority referral information outlined significant risk relating to their support, the risks included self-harm, including cutting and using a ligature, and risks to staff including unfounded allegations. The provider had not assessed the risks and provided guidance for staff to mitigate these. In addition, people with a learning disability and autism had complex communication needs. They did have risk assessments completed by the provider, but these directed staff to follow ‘Positive Behaviour Support (PBS) strategies’ without any indication of what these were. These people’s records did not include clear guidance for staff to follow. Notwithstanding the above, there were risk assessments for 4 people relating to their home and environment. One relative said, “They (care workers) respect our home and they 100% know what they are doing, I trust them.”

People's care and support was provided in a safe environment. One relative said, “They (Care workers) respect my home and keep it tidy and clean even when there is a mess.” The provider carried out a risk assessment of home environment (except for one person’s home), including fire, safety of the hoist and mobility equipment and gave guidance for care workers to provide care to people in a safe environment.

There was an absence of robust and safe recruitment practices to make sure that all staff, including agency staff and volunteers, are suitably experienced, competent and able to carry out their role. For example, there was no disclosing and barring service (DBS) check completed by 24/7 Divine Healthcare Ltd for 7 care workers. These had been done by another employer. In the absence of up-to-date DBS checks, the provider had not carried out each care worker’s risk assessments and developed mitigation plans. Employment references for 5 care workers were not held within their file, and these were not provided to us during the course of the assessment. Right to work supporting records for 5 care workers were also not available. We were not assured the provider had ensured that service users received safe care and treatment from staff that were suitable.

The provider ensured there were enough care workers on duty. People and their relatives told us they never had a missed call. One relative told us, “They (care workers) are always on time, never late. They also stay longer when needed.” Another relative said, “The care workers are not rushed.”

However, the provider did not always make sure care workers received supervision or appraisal of their work. Records showed most care workers were trained in all mandatory subjects such as medicines management, moving and handling, dementia awareness, learning disability, safeguarding adults and children and achieved the Care Certificate. However, 1 care worker who usually worked with a person with a learning disability, who exhibited significant distress on most days they received support had not been trained in any mandatory subjects, including positive behaviour support. One relative told us, “To make things better I think there could be more training (for care workers) in the service.”

People were protected from the risk of infection. Care workers understood the importance of effective hand washing, using personal protective equipment (PPE) and disposing of waste appropriately. This protected people from infection and cross-contamination.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.For example, a person was prescribed morning, afternoon, and evening medicines. However, the medicine administration record (MAR) chart from 14 November 2025 to 11 December 2025, showed their evening medicines were left blank on most days. A person was prescribed PRN (as required medicine) and their MAR chart showed a care worker administered PRN on 5 December 2025, however there was no reason recorded why it was administered and the outcome. Also, there was no PRN protocol to guide care workers. We brought this to the attention of the NI, they told us how they plan to make improvements.