Efficiency Health and Homecare Services - Malmesbury

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was previously in breach of the legal regulation in relation to governance. Improvements were not found at this assessment, and the provider remains in breach of this regulation.

This service scored 36 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider told us the vision and strategy were shared during induction. However, we spoke to staff who were unable to explain the provider’s vision or strategy. Comments included “I am not sure” and one staff told us when they were looking for guidance and direction “It feels like the office staff know more than the manager”. The vision was not easily accessible to staff. Leaders told us this was shared during induction. However, we were not provided with evidence of this. This meant that a shared direction had not been cascaded effectively and the provider could not be assured that staff were working in line with their current vision.

However, staff told us that the provider was flexible. Comments included “They show me flexibility around my children” and “They support me with lifts as I don’t drive”.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

We viewed numerous documents which evidenced that leaders did not have the knowledge to ensure that support was provided to people that met their needs. For example, we were provided with risk assessments written by leaders which did not contain accurate information about the needs of the person supported. The registered manager did not have a clear understanding of the persons needs when they completed the risk assessment. The risk assessment did not identify the correct support required by the person. We spoke to staff and the person, they confirmed this information was incorrect.

Competency assessments to complete a delegated healthcare task had been completed with staff by leaders who did not have the skills, knowledge or appropriate training to complete this in line with regulations and good practice. Only a healthcare professional was qualified to complete these competency assessments. These competency assessments contained the same inaccurate information as the risk assessment. The provider did not have systems to identify errors such as these. Inaccurate information had been used to form guidance for staff when supporting people. This meant the provider could not be assured that support for people was safe and that risks had been identified and mitigated.

We had extensive communications with leaders regarding the requirements needed for them to support a person with a delegated healthcare task. However, leaders had not actioned this and did not fully understand legislation and regulations regarding this.

However, staff we spoke to said leaders were approachable and helpful.

People did not always feel they could speak up and that their voice would be heard. The provider had posters displayed within their office to support staff to understand how to speak up. They had a policy to give guidance to staff on how to speak up. However, staff had raised concerns about their pay. The provider had not taken action to address these concerns. A staff member told us there were still concerns related to late payments to staff and they did not feel there were efficient processes to address this.

We were also told by a staff member that they had made repeated attempts to engage with the provider regarding their concerns but did not feel they had been heard.

We were also told by a staff member that they had raised concerns about medicines. However, leaders had not investigated these concerns or taken actions to resolve them.

The provider did not address concerns in line with their policy and did not take sufficient action to resolve these concerns. This meant the provider could not assure themselves that their systems and processes supported freedom to speak up.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We viewed 6 staff training records, none of these 6 staff had completed equality and diversity training. The list of training by the provider for all staff did not include any equality and diversity training.

Meeting and supervision records did not contain any evidence that equality and diversity was discussed or considered. This meant that the provider could not be assured that they promoted equality and diversity within their service.

However, staff did not raise any concerns with us in relation to equality, diversity and inclusion.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

When we visited in January 2025, we issued the provider with warning notices which highlighted shortfalls and a timescale set to complete action. However, when we visited again in October 2025, we found actions had not been taken to make improvements.

During our assessment in January 2025, we found people’s care plans did not contain accurate information or contain enough detail to enable staff to support people safely and in line with their preferences. During our assessment in October 2025, we were told that this had been completed. However, when we viewed care plans, we found that they still contained inaccurate information. For example, one service user had Parkinson’s disease, but this was not recorded in any area of their care plan. One person had a condition that heightened their risk of falls and no details were recorded in their care plan.

We highlighted in January 2025 that risks people faced had not been identified or mitigated. During our assessment in October 2025, we found that risks had still not been identified or mitigated. For example, one person had no risk assessments for any areas of their support. Another person was transported by staff to appointments, but there was no risk assessment in relation to this.

During our assessment we requested information from the provider, yet the information provided was often inconsistent. For example, we requested a risk assessment related to staff transporting people in vehicles. We were given conflicting information regarding this. The Registered manager informed us they did not transport any people in vehicles. However, we viewed a care plan which stated that staff transported people to medical appointments, we spoke to a person supported who confirmed this. There were no risk assessments in place for this person or for staff, the provider did not hold information related to staff driving. This meant the provider could not be assured that risks had been identified and mitigated or that appropriate insurance was in place to ensure people’s safety.

Processes and systems which the provider used to drive improvement and audit these improvements had failed to identify shortfalls. For example, we were told that care plans had been reviewed and updated to ensure that accurate and detailed information was recorded. However, we viewed 5 care plans all of which contained inaccurate information and had essential details missing. For example, reviews of a person’s care records had not identified that the Local Authority needs assessment did not match the support being given by the provider. This meant that the support being provided to the person did not meet their needs.

Medicines audits did not identify all errors and there was not an effective system to take action against shortfalls identified from this audit. The provider had not completed any audits related to infection prevention control. This meant that the provider could not be assured that shortfalls were clearly identified and actions taken to address any shortfalls.

The warning notices issued in January 2025 were clear regarding the improvements required to meet the Care Quality Commission regulations. However, due regard had not been made to these warning notices. The provider had not ensured that systems and processes were developed to make improvements and monitor actions taken. This meant that changes had not been made to ensure people were supported safely and in line with their needs and preferences.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. The provider did not effectively collaborate with professionals such as health care professionals. For example, the provider had not communicated with the district nursing team to ensure that training was provided to staff for a delegated nursing task.

The provider had not liaised with the dementia specialist nurse to ensure that annual reviews were complete for people with dementia. This meant that services could not always work seamlessly for people to ensure their needs were met.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

During our first assessment in January 2025, we highlighted shortfalls to the provider. When we revisited to complete this assessment in October 2025, we requested to see an action plan that addressed the areas of improvements. The action plan contained inaccurate information, there were areas noted on the action plan that stated actions had been taken to address shortfalls. However, when we reviewed documents, we found that these actions had not been taken and improvements had not been made.

Staff we spoke to were aware of areas of improvements required. However, there were no clear systems or processes to ensure staff were aware of their responsibilities or tasks assigned to them. There were no clear timescales set to ensure shortfalls had been addressed. During this assessment we found that improvements had not been made against any of the areas we had previously highlighted to the provider.

This meant that the provider had not focused on continuous learning and improvements and could not be assured that support provided was safe or meeting the needs and preferences of people they supported.