Frank Care Devon

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 regulation in relation to safe staffing and recruitment.

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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

In some areas the service leaders were working to improve the culture of learning in the service. For example, incidents and accidents were being investigated and responded to. However, there were significant cultural issues with the management of the staff team by the service leaders. This was impacting on the quality of the service being received by the people. For example, in the timeliness and consistency of peoples’ support.

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 service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. Though there were difficulties with relationships with stakeholders, we were satisfied people’s care pathways were safe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff had received safeguarding training, and staff and managers were aware of safeguarding processes to use if necessary.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. which is part of the). We checked whether the service was working within the principles of the Mental Capacity Act 2005 (MCA) within their community service. We found all those who used the service had capacity to make informed choices.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some risk assessments relating to the health, safety and welfare of people using the service were being completed. However, there was a lack of detail to demonstrate what the risks were and how they were mitigated. Risk assessments contained a tick box list of equipment used with each person, rather than a detailed description of each risk impacting the person and how staff could support them to reduce or manage each risk.

One person had complex needs due to a degenerative condition. Care staff were taking part in all elements of this person’s personal care including supporting the person to eat and hoisting from their bed to a shower chair. There was no direction in either the person’s risk assessments or in care planning to direct staff how to carry out these actions safely.

There was no detailed risk assessment for a person’s risk of choking. Care staff confirmed risk assessment information made it difficult to manage risk safely. We were told by the registered manager that a Speech and Language Therapy (SALT) assessment was carried out recently to assess the person’s ability to eat and swallow. We were told this assessment had directed the person’s food was to be cut into small pieces to mitigate their risk of choking. The service did not have the directions from SALT on how to prepare the person’s food and how to assist them to eat. The support to be given by care staff with eating was not written within the care plan, or in a risk assessment. Care staff were delivering care to highly vulnerable people with insufficient and unclear information which impacted on the safety of the care given. This lack of clear guidance for staff placed people at risk of harm.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Risk assessments were in place for people’s accommodation to ensure a safe working environment for staff to deliver care in. Where people had equipment in their homes for staff to use, the service ensured this equipment was safe for staff to use.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

On our first visit to the service office, we heard one person call the service to say the care staff had not come to them for their visit. A replacement was quickly arranged to go to the person; however, we were told this person needed their visit times to be on time to meet their emotional needs. When they called the service office, they were in distress. Records for April 2026 for this person showed there were 12 occasions when care staff were between 30 mins and an hour late arriving at their home.

We saw the arrival and departure time visit record which showed care staff had frequently arrived very late for visits for people receiving personal care since February 2026. These late visits were often over 30 mins late and sometimes more than an hour. We heard from staff there were now not enough care staff who could use cars, and some of the remaining 12 care staff with the service relied wholly on public transport or walking, to reach peoples’ homes. This meant care staff could not travel between visits in the time made available on the rota.

One person said, “Carers can sometimes be late due to public transport and don’t always inform (me). It happens maybe twice a week. By half an hour to 2 hours. Yes, it’s inconvenient and I have to wait if 2 carers don’t turn up. I have one carer 24/7. I told the company (about lateness). At the moment they are quite short of staff”. Another person said, “Carers don’t always come on the same time. It’s not inconvenient for me. But it panics (the person receiving the service)”.

Some people said care staff did not always give them confidence, and they were no longer able to have choice of care staff or had to decline certain care staff if they wished to keep the service. One person said, “They (care staff) work hard and try to do things right. The good ones are really thoughtful and go out of their way to support me. Others just do the basic minimum. I’d say at the moment that’s 50% or 2 out of 4 (care staff). I don’t have enough choice at the moment (of care staff)”.

The service had failed to provide competent and adequately trained care staff to meet peoples’ needs effectively or to give people confidence in the skills of the care staff. People and their representatives said care staff were not always competent, skilled or trained to either meet their needs or give them confidence. An advocate said, “The agency doesn’t provide adequate training for carers (care staff) who haven’t worked with specific (people) before and therefore they don’t know what their needs are. They rely on others who don’t work for the agency to train the carer (care staff) in the (person’s) needs.” A person also said, “New carers don’t know my needs. There’s not enough shadowing first. It depends on who is working. They try. Some are more competent” (than others).”

Staff had not always received training to meet individuals’ needs. One staff member had not taken part in any mandatory training as required by the service, since they began supporting people in 2025. Only 3 of 12 employed care staff had completed the Care Certificate since beginning employment with the service.

Care staff confirmed they had not received sufficient or specific training to meet individuals’ needs. They also said care staff were expected to manage in complex care situations without adequate preparation and support from the provider.

Staff had not been recruited safely as the necessary checks had not been carried out when new staff began working directly with vulnerable adults in their own homes and without direct supervision. Disclosure and Barring Service (DBS) checks had not been carried out in a timely manner for each new staff member and reference checks had not been carried out appropriately. For example, one staff member who had been working for the service for more than 3 months and was from outside the UK had not had a DBS check carried out and no application had been made for one. We were told the service requested 2 references but only from previous employers. However, we saw several staff had not had a second reference obtained and in some cases no references had ever been obtained before staff members were employed. This staff member did not have a DBS check, had only had one reference requested by the provider and this had not been received back. Therefore, this new staff member who had been working unsupervised with vulnerable people in their own homes had not had a check made of their police records or of the national barring register. The service had also obtained no information from previous employers about their credibility. These failures in the recruitment process placed people at risk of harm of working with staff who were potentially not suitable.

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 were supplied with Personal Protective Equipment (PPE) to carry out their roles. For example, there were stocks of PPE in each person’s home and in the services office for staff to use. Staff and people told us PPE was being used by the staff.

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.

Care staff were routinely signing a record of medication to record a medication as taken. However, none of the people supported by the service needed staff to support with the administration of their medicines. There were concerns raised in feedback that records to sign for medication were not being kept up to date and accurate, when these records were not necessarily needed. The management of the service said they would act to address this situation.