Care Quality Services IOW

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 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 provider was in breach of the legal regulations relating to safeguarding and staffing.​

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 had a culture of safety, based on openness and honesty. Lessons were learnt to identify and embed good practice. There was a process for safety events such as accidents and incidents to be reported, recorded, investigated and actions taken to mitigate against future similar events. A duty of candour policy was in place.

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. Referral information was received from the local authority, and this was used to determine if the person’s needs could be met by the service. In person assessments were then completed by a member of Care Quality Services IOW staff as part of the care planning process. If the person needed their care to be transferred to another service we were assured that any relevant information about medicines, health or care needs would be shared appropriately.

The provider did not 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 avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

The management team had not always taken appropriate action where necessary in response to safeguarding concerns. We identified a family member and care staff who were placing a person at high risk due an unsafe method of supporting the person to meet their nutritional needs. This had been noted on daily care records in July 2025 and an office staff member had approved for staff to support the person in this unsafe way. No assessment by a suitably qualified external professional, training for staff or risk assessments had been completed. Once identified to the registered manager they took immediate action to safeguard the person.

Staff had completed safeguarding training however, most did not feel that their responsibilities extended beyond reporting to the office or left the reporting of concerns to senior care staff who also undertook some care calls. For example, they had not reported concerns about unsafe methods of supporting a person to meet their nutritional needs or where mobility equipment was placing the person at risk of injury.

Whilst reviewing records of accidents, incidents and complaints we found that the local safeguarding team had been informed of these. However, CQC had not been notified of all safeguarding concerns as is required by legislation.

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.

Not all risk assessments were in place. For example, where staff were supporting a person who required their food in a modified texture to ensure their safety when eating, the use of an unsafe method to support a person to receive their nutritional needs, risks relating to some prescribed medicines and a person identified as being at risk of choking but had no care plan to manage this risk. The failure to ensure all risks were identified, assessed and safely managed as far as possible by staff meant people were at risk of harm whilst receiving care.

Other risk assessment were in place to ensure people’s needs could be safely met and managed, however these sometimes lacked all information or were inconsistent with other information in care records. Care staff confirmed they had access via their phones to risk assessments on the provider’s electronic care management system, although staff told us some care plans and risk assessments needed to be updated. Once identified to the management team prompt action was taken to update these records.

Care staff said they could always contact the office if they were unsure about anything although were less confident of support out of hours indicating they would only contact the providers national on call system if absolutely necessary.

There was a business continuity plan which identified people who required priority of calls based on individual risk in service emergency situations such as severe weather.

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 associated with the person’s home environment were completed before the service started supporting people. Assessments noted if smoke or carbon dioxide detectors were in place but not who was responsible for checking these were working on a regular basis. The registered manager agreed to add this information to the assessments. The registered manager knew how to access specific equipment should this be required and staff confirmed they had received training to use equipment safely.

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 to provide safe care that met people’s individual needs.

Some people or their family members told us they had consistent care staff however, others said there was a lack of staff consistency with multiple staff attending them each week. Records of staff visits for some people showed a high continuity of staff and others a lot of different staff attending over the week. There was also variability in the timing of calls with some people having calls at consistent times and others where calls were not always spaced or timed to meet people’s needs. For example, a person commented on the timing of care calls saying, “Last night I had a 6.30 evening visit and I am now waiting for my carer this morning who comes at 10.30 so that means that I have an 18 hour gap between visits which is not good.” Other people told us about similar concerns with timing of care calls.

People, family members and visit records confirmed staff generally stayed for the full length of the call although provider audits showed this was at 72% with a target that this should be 75% minimum. Care staff told us they did not always have any or enough travel time between calls. Staff rosters reviewed did not always show any or sufficient travel time was in place between allocated care visits. This meant if staff stayed the full length of the care call they would become consistently later for subsequent calls.

People or family members told us not all staff knew how to use equipment and did not appear fully trained. For example, a person told us not all staff could change their stoma bag as they did not know how to do it meaning this was not always changed when required. Another person said, “Sometimes they use a Sarasteady [moving and handling equipment] for me but they do not all know how to use it.”

Staff were positive about their training although some confirmed they had not received some training specific to the needs of people they were allocated to care for. For example, a staff member supporting a person with diabetes said they had not received diabetes training. The registered manager confirmed staff supporting a person with epilepsy had not received this training. Newer staff told us induction training had helped them and they had undertaken shadow shifts to help them gain the basic skills they required.

There were appropriate pre-employment processes. Records viewed showed most necessary checks had been completed. However, whilst the recruitment policy correctly stated that evidence of satisfactory conduct in all previous work with vulnerable people should be sought this had not occurred in records viewed.

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 received food hygiene and infection control training. People and family members confirmed care staff used Personal Protective Equipment (PPE) where needed. The management team understood the actions they should take should there be a specific infection risk or concern for an individual person. A person told us, “I have no issues with hygiene standards, both personal appearance and domestic. They [care staff] wear all the protective clothing.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Staff had received training to administer medicines and their competency was assessed on a regular basis. Information about medicines was included in care plans although this did not include information as to what each medicine was prescribed for or some risks relating to these. The registered manager agreed to add this information to care plans.