Caremark North Norfolk & Great Yarmouth

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 Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service demonstrated an effective learning culture. We saw from the minutes of team meetings and findings from audits and spot checks, that issues were identified and discussed, lessons learned and changes made to improve things.

Staff spoke positively about the open culture within the service. They also said that incidents were discussed and reviewed and told us, “Regular team meetings are also held, providing opportunities to share information, discuss any issues and keep everyone up to date.”

The registered manager told us, “We share information on our [workforce app] with all members of staff. We also share information in team meetings so that we can do ‘lessons learned’ and see what we can do better.” And, “We investigate matters and we are curious to see what has happened and how it has happened. What went wrong and when it went wrong.”

People and their representatives also told us that staff and management were responsive to feedback and took learning from any errors or shortfalls and took action to help avoid recurrences.

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.

The service had clear systems and processes in place to support people with any transitions regarding care and support. For example, staff met with people prior to providing care to gather detailed information about the person, find out what was most important to them and establish how they wanted to be supported. Staff also liaised with other health and social care professionals involved in people’s care to gather information about their health and wellbeing and support continuity of care.

The service worked hard to ensure that, as much as possible, people were supported by the same care staff, so they could build up positive and trusting relationships with them.

A person told us, “Most of the time I have the same carers, so they know me well and I know them.”

People and their representatives also told us the service was responsive and accommodating to people’s changing needs.

A member of staff told us the best thing about working for the company was, “You are able to support people in a way that they wish to be cared for. You are not doing anything to meet the service’s needs; it is to meet the customers’ needs. I always thought that was what care was and here we are able to do it.”

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.

People told us they felt safe using the service. A person told us, “I feel 100% safe from abuse or harm when I'm with the care workers.”

A person’s representative said, “I had low expectations, but the carers are good. They are consistent and we are happy with the care, I know [relative] is safe.” Another representative told us, “I live a long way away and it gives me full peace of mind knowing my [relative] is safe.

Staff completed training for safeguarding people. They told us they were confident about raising safeguarding concerns and understood the reporting processes.

A member of staff told us, if they had any concerns about a person they were visiting, they would log it in the daily notes, complete a body map, if required, and report it to the office. Staff also told us they would report any concerns directly to the safeguarding team or CQC if necessary. This showed staff were empowered to act and that concerns were taken seriously.

The service worked in line with local safeguarding procedures. Statutory notifications were also submitted appropriately for safeguarding incidents, which helped demonstrate transparency and compliance with regulatory requirements. Where concerns were identified, investigations were carried out and any learning or improvements required were clearly identified and implemented.

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.

The management team and care staff identified and assessed most risks to people’s safety. Clear risk assessments and management plans were available in people’s care records. Care staff told us that people’s care records provided them with detailed information about how to support people safely. Risks were regularly reviewed and risk management plans were adjusted as and when needed.

People explained how staff supported them to stay as safe as possible. For example, a person told us, “They help me have a shower safely and make sure I don’t fall.”

However, where a person was prescribed emollient cream, there were no risk assessments in place to help mitigate the fire risks associated with emollients. It is important that people using emollients are supported to understand and manage these risks, because emollient residue builds up on clothing, bedding, and dressings and acts as a severe accelerant. The provider and registered manager acknowledged this and provided evidence to show the immediate steps they had taken to ensure appropriate risk assessments were completed for people.

The provider had effective systems and processes to identify risks and hazards in people’s home environments. Environmental risk assessments were completed with people using the service and risk management plans were compiled to help mitigate identified risks as much as possible.

People told us staff completed needs assessments and risk assessments when they began using the service. These assessments included health and safety for themselves, as well as staff, within their individual home environments.

Staff also ensured people had access to the equipment they required and this equipment was kept in good working order.

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.

We analysed the data from the provider’s electronic call monitoring system for July and August 2026. We were assured that care visits were managed well and the system was being used effectively. There was no evidence of any missed calls and we saw that punctuality was very good, with 93% of calls delivered within 15 minutes of scheduled times. Consistency of staff for people was evident and staff had travel time factored in between calls. We did not identify any issues with the service delivery and none of the staff appeared to be working an excessive rota.

Comments from people using the service also supported our findings, with comments such as,“The care workers regularly arrive at the time agreed.” And, “I have 2 carers, so 1 of them is usually here to tell me if the other is going to be late.”

People using the service also confirmed that staff stayed for the agreed amount of time and were trained well.

A person’s representative told us, “The carers are always punctual, polite, respectful and show consideration towards both my [relatives]. I have no concerns about them whatsoever.

Staff confirmed that they completed comprehensive training, were supported well and had regular ‘spot-checks’ of their work. Staff told us, “All e-learning is provided, as well as face to face training.”

The provider followed safe recruitment practices, to ensure suitable staff were employed. This included checking people’s identity, their eligibility to work in the UK, criminal records checks, obtaining references from previous employers and a thorough interview process.

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 completed training for infection prevention and control and understood their responsibilities. Staff confirmed they had enough personal protective equipment (PPE), which helped reduce the risk and spread of infection.

Regular spot checks were carried out by the management team, which also included observing health, hygiene and infection control practices.

People and their relatives also confirmed that staff adhered to good infection control procedures.

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.

Care staff had completed training for the safe management and administration of medicines. The management team completed regular competency assessments in this area, to ensure staff understood and adhered to their responsibilities.

We saw there had been some errors in respect of some people’s medicines. However, we saw the provider and management team had also quickly identified these errors and had taken action to rectify the problems. The provider and management team regularly audited and closely monitored the management and administration of people’s medicines and any issues were recorded in action plans and discussed with staff.

We were assured by the provider’s actions as well as their openness and honesty during this assessment. The provider told us, “As you will see from our governance records, the medication issues have been identified, recorded, reviewed and tracked, with actions put in place and further monitoring undertaken. We recognise there have been areas to improve and have been actively working through these. Hopefully the evidence provided demonstrates the learning and improvements that have taken place.”

People and their representatives told us they were happy with the way the service was managing people’s medicines. A person’s representative told us, “Caremark have helped to sort out the blister packs for [relative]’s medication and they have organised a locked [medicines] box.”