Cornwall Home 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

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 care and treatment, recruitment and governance.

This service scored 53 (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.

Records showed that accidents and incidents were not always documented, and staff did not understand the importance of reporting concerns. For example, daily notes indicated one person was red and sore in the groin area. This had not been recorded as an incident. This meant opportunities to learn from incidents might be missed. Investigations did not include sufficient analysis and/or follow-up to understand underlying causes.

Staff told us they felt comfortable raising concerns and were confident these would be addressed by management. One person said, never had to raise a concern “All very good.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Care plans were out of date. One care plan had been dated as having been reviewed on 23 July 2026 but had not updated to reflect the persons changed needs, therefore we could not be assured they were an accurate reflection of people’s current needs. This is particularly important if people are admitted to hospital in an emergency.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People reported and demonstrated through their actions they felt safe with their support staff. We observed people were comfortable requesting support and reassurance from staff. People and relatives told us, “I feel safe” and “I trust all the staff that visit my [relative] and I know they will keep [relative] safe as well.”

Involved health care professionals were complimentary of the provider but had concerns about a decision-making process which included restricting one person’s ability to leave their own home. Whilst the provider had made the decision with the person’s advocate, the initial process did not include commissioned oversight and agreement. Following this being identified a best interest process was instigated and appropriate adjustments made.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. We checked whether the service was working within the principles of the Mental Capacity Act. We found staff supported the majority of people in the least restrictive way to ensure people and their families felt in control of their care.

Not all staff had a good understanding of local safeguarding procedures. Most staff said they were confident any safety issues they raised would be investigated and resolved However; one member of staff was not sure how quick concerns were seen from the providers app.

There were processes to ensure people were protected from financial abuse. Where the service provided support with shopping tasks, the providers electronic app held copies of the receipts which were sent to the council for auditing.

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

Risk assessments had not been updated to ensure they were still relevant and provided staff with the guidance they needed to support people safely. Some identified risks had not been assessed. For example, one person who was at risk of falls and had dementia, had no risk assessment or guidance for staff on how to support the person during these times.

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

Care plans included environmental checklists, highlighting potential hazards such as gas, electric and water and where these supplies could be located should they need to be shut down. This supported staff to respond appropriately and safely when working in people’s homes.

Systems did not ensure people consistently received care in line with their assessed needs. The rotas showed there were 192 short calls, where staff spend less than half of the planned call time with people, this equated to 18% of the total calls over a 4 week period.

Safe recruitment processes were not consistently followed in line with the service’s policy. Two members of staff had start dates before their Disclosure and Barring Service (DBS) check and references had been received. For example, a staff member started on the 19 February 2025, however, the DBS check was received on the 1 March 2025 and the reference on the 14 August 2025. There were no interview notes kept, or questions that explored candidate’s previous experience and knowledge. This can help employers make decisions about candidate’s suitability for the role.

Not all staff had supervision or appraisals. However, staff told us they felt supported and able to raise concerns or seek advice when needed.

One member of staff had not had an induction, induction training helped ensure new staff had appropriate skills and knowledge to support people in line with their needs and preferences.There were enough staff to meet people's needs and people told us they "always turned up."

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 had access to good stocks of Personal Protective Equipment (PPE), including gloves, aprons, and hand sanitiser. Staff told us PPE was readily available and could be replenished when needed. One staff member told us, “We have a constant supply of PPE, it’s kept in a box in the car.” We noted during home visits that PPE was used and people told us, “Staff always wear PPE and dispose of it safely.”

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

Improvements were needed to the way medicines were managed. There were gaps in people’s medicines records. We saw medicines administered were not recorded on the Medicines Administration Record (MAR). There was no guidance for staff on when to administer or how much should be administered. Because no administration record was kept, staff did not know when the last dose, or how much, had been administered and could therefore not ensure sufficient gaps between doses, in line with the manufacturer’s guidelines. This put people at risk of harm including overdose. There was no record kept of when medicines were opened so that they could be destroyed in line with their shelf life.

If medicines were prescribed to be taken ‘when required’ there were protocols to guide staff when these might be needed, but staff were not following these.

When medicines were applied in the form of patches, staff recorded the site of the patch within administration records, but failed to record on a body map, in line with best practice. This put people at risk of harm because failure to rotate the site can cause skin irritation and reduce the effectiveness of the absorption of the medicine into the body.

Staff told us they had in-house training and competency checks to make sure they gave medicines safely. Audits had not been routinely completed in the months prior to this assessment. This meant opportunities to identify shortcomings had been missed.