The Caring Company Rutland 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. At our last assessment we rated the service good. At this assessment the rating has changed to 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 people could be harmed.

The service was in breach of the legal regulation in relation to assessing risks to health and safety of service users and ensuring person’s providing care and support had the competence and skills to do so safely and the safe management of medicines.

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

The provider told us data including accidents and incident records and investigations had been unlawfully deleted.

The provider could not evidence any investigations or learning from accidents and incidents because systems and processes were not in place regarding oversight and analyses of accidents or incidents. The provider told us a full review of their accident and incident and accident reporting process was underway.

A staff member we spoke with told us what action they took in the event of an accident or incident, they showed us an accident form for a person who had fallen and required hospital treatment. The accident record contained important information about what had happened and what action the staff had taken. However, there was no analysis of cause or further risk reduction strategies. The person had a known need for support with their mobility; however, the care plan and risk assessment did not clearly set out how staff should manage this risk.

We were not assured the provider understood current risks. The provider sent us an action plan in response to concerns we raised at our first site visit. Although they had begun to take action to address concerns and risks, they had not acted in a timely manner or met all the timescales set out in the action plan.

There was no evidence of ongoing communication with staff such as team meetings or staff supervisions to discuss safety events or known risks. The provider had begun to hold governance and staff meetings, but these had not been routinely taking place.

We could not be assured safety and continuity of care was a priority throughout people’s care journey. People had not had their care and support reviewed for several weeks and had not been involved in any review of their care plans and risks assessments. The provider did not always manage or monitor people’s safety.

People told us the referral system had been a positive experience for them; home visits were arranged and the needs of the person and relatives were discussed and documented. One person said, “Initially the company came and assessed the house, when my [family member] returned from hospital they came out to meet them. I can’t fault the assessment they did, they included us both.”

Another person told us, “When [family member] returned from hospital the carers identified a sore area on their skin and treated it promptly.”

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. The provider did not always share concerns quickly and appropriately.

People were not always supported to understand their human rights, rights under the Mental Capacity Act 2005. People did not have their mental capacity assessed. There were no best interest decisions recorded in care plans. This meant people were not supported to understand information, communicate and make decisions about their life, care and treatment in line with the MCA.

There was no management oversight of people’s experience or safeguarding risks. People were not provided with opportunities to share their experiences of care and support received.

Records showed the majority of staff had attended level 2 training about safeguarding people from abuse for adults and children as required to.

A staff member we spoke with knew how to recognise the signs of abuse and what action to take if the suspected abuse had occurred.

People we spoke with told us they felt safe with staff and did not have any reason to raise any concerns.

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 was safe.

People told us staff supported them to manage risk. They told us how staff supported them with mobility needs. They knew how to do this in the correct way and how to use any equipment safely. A relative said about staff, “They know what they are doing, I have never had any concerns. My [family member] is at risk from falling, they manage this by walking beside them.”

While people and their relatives expressed overall satisfaction with the care and treatment, we found elements of care did not meet the expected standards.

Risks relating to people were not fully assessed or managed appropriately. There was no evidence people were involved or supported to understand decisions about this.

Risk assessments and care plans did not provide enough detail about people’s individual risks and the risks associated with receiving care. For example, risks associated with swallowing difficulties, the use of equipment and known risks in people’s daily routines were not sufficiently explored or planned for.

A lack of management review and audit meant the provider could not be assured people and staff understood all risks or how to manage them.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Each person had a care plan regarding their environment, however it was not clear what risks had been identified or what action staff should take, including what staff should do in the event of a fire or emergency.

The provider was introducing a new environmental risk assessment. This was comprehensive and designed to identify and manage all known risks. However, it had not yet been fully embedded or tested.

Records showed staff had not received fire safety training or this training had expired. We could not be assured staff had the training they required to keep people safe.

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.

At the time of our site visit the provider did not have effective oversight of staff skills and experiences. This meant the provider could not be sure staff had the required training and knowledge to meet people’s needs and keep them safe. There were no records of staff competency checks having been carried out.

Following our first site visit the provider took action to verify existing staff training and commence retraining for all staff. However, significant gaps in staff training records remained for essential training staff required to keep people safe such as moving and handling. There were no records of staff supervision having taken place.

People told us they received support from a consistent team of staff with the right skills and experience. They told us staff arrived on time and stayed for the required duration.

We looked at electronic records for calls and call times for the previous 3 months. These showed care and support calls were attended by a consistent team of staff. Staff arrived on time and stayed for the planned duration of the call.

The provider followed safe recruitments procedures. Checks were conducted before employment was offered to ensure staff had the correct skills and experience.

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.

People told us staff wore appropriate personal protective equipment such as gloves and aprons and followed expected hygiene standards such as handwashing. One person said about staff, “They always leave their room clean and tidy, and empty the bins.”

The provider had a policy about infection prevention and control as required. Staff had access to training about infection control and hand hygiene. However, it was unclear from the records if staff had attended this training.

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

At the time of our fist site visit, training records for the management of medication were either not available for review or recorded as out of date. There were no records available of staff competency checks for the management of people’s medicines.

The provider did not routinely check medicines management records or procedures. There were no audits available for review. Managers had not had sight of any medication administration records for the previous 8 weeks. This meant the provider could not be assured people had received their prescribed medicines in the correct way or as prescribed.

Medication administration records we reviewed for April 2026 were handwritten but there was no clear process to ensure the administration records matched the prescription or had been checked for any errors. Where medicines were prescribed on an as required basis, there were no protocols in place to instruct staff about when these medicines should be administered.

The provider took immediate action when we told them about our concerns. This included carrying out a full medication audit and moving all medicine records to an electronic system to enable real time audit and manager oversight. Protocols were introduced detailing when and how staff should administer these medicines.

People told us staff supported them with their medicines. One person said, “They give me my medication out of the dossett box and into an egg cup. They make sure I take my inhalers and I have my antibiotics after food. They take my blood pressure every day, contact my GP if I want them to.