Quodesh Healthcare Consultancy 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 regulation in relation to the ways people’s medicines were managed.

This service scored 59 (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.

The service had processes in place for staff to report incidents and take action where appropriate, however these were not always effective. Concerns were raised by a relative about incidents that had happened linked to catheter care. The registered was not aware of these incidents. They investigated the concerns and discussed it with staff to prevent it happening again.

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.

There were processes in place to ensure people’s needs were assessed before commencement of a care package.

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.

There were safeguarding policies and procedures in place, and these were being followed.

The registered manager was aware of their responsibilities under safeguarding and staff had received training in safeguarding adults and knew how to report abuse and neglect. A staff member told us, “If I became aware of any safeguarding concerns about a service user, my first priority would be to ensure the person’s immediate safety. I would then stay calm and listen carefully. Record the facts accurately and report the concern immediately to my line manager.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s care plans were detailed with their main health risks and guidance was in place for staff on how to support people to manage those risks. A person supported by the service was diabetic and their care plans detailed what support they required to prevent incidents of high or low blood sugar. Another person lived with dementia and required additional support with their mental health; their care plans described how their needs presented and what staff should do to offer the appropriate support.

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

The registered manager conducted risk assessments regarding the environment and made sure staff knew how to use equipment safely. Checks were also completed to ensure equipment used to lift and move people was safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Relatives told us their loved ones were supported by a consistent team, who arrived on time and stayed for the full duration of the care visit. A relative said, “Because they are a regular group of carers, they know [person] and can let me know if there is anything wrong.”

However, we found inconsistency in the quality of safe recruitment checks. These were not always completed in line with the provider’s own policies and procedures. We found gaps in employment were not always explored and origin of references were not always evidenced. Other aspects of recruitment were safe.

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.

There were policies and procedures in place to control and prevent the spread of infections. These were being followed. Relatives did not share concerns in this area.

The provider did not make sure that medicines and treatments were safe and met people’sneeds, capacities and preferences.Staff did not always involve people in planning.

Medication was not always safely managed. We found gaps in medication administration records. Between July and September 2025 there were instances where medication was not signed for as administered. We raised our concerns with the registered manager. They investigated the concerns and put a plan in place to address these concerns.

We found evidence of secondary dispensing of medication taking place; which is an unsafe practice. We discussed this with the registered manager, and they updated us on the action they had taken to prevent it happened again.

Staff and relatives were sharing the responsibility to administer medication, but this was not clearly documented in people risk assessments or care plans. We discussed this with the registered manager and before the end of our assessment, they updated us on actions taken.

We reviewed medication audits and we found no recent medication audits had been completed, and the ones completed some months ago had not been effective in identifying and addressing the issues found at this assessment. Staff had their competency to administer medication assessed.