Just Call 4 Care Services

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• 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 this key question 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 that people could be harmed.

The service was in breach of legal regulations in relation to safe care and treatment and staffing.

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 always have a proactive and positive culture of safety based on openness and honesty. Some risks to people were not planned for, for example, moving and handling care plans lacked detail, and some care plans needed more detail to guide staff on supporting people with their health conditions. There was a system in place for recording incidents. However, there was no analysis of incidents completed, and it was not always clear how lessons learnt from incidents were used to drive improvements and mitigate future risks. Wediscussed this with the management team and by day 2 of the inspection some improvements had been made to show more clearly where lessons had been learnt from incidents.

Staff told us senior staff were responsive and supportive in dealing with any matters they raised and were confident they would be dealt with.

People who had shared their concerns to the office team reported varying levels of satisfaction with how these were dealt with. People told us they mainly communicated directly with the care staff who supported them with any queries or concerns. Whilst this seemed to work well for people, it was unclear how the information shared was escalated to the management team or captured and used to drive improvements at the service.

The provider worked with people and healthcare partners. However, people’s care records did not always accurately or fully reflect their needs or provide sufficient guidance to staff to allow them to support people safely, for example, moving and handling needs and information about specific health needs. The lack of detail, and clarity and in some records, increased the risk of care pathways and transitions not being safe, as the information being shared was not always accurate or up to date. However, many people received support from a consistent staff member who knew them well.

We had contact from 2 health and social care professionals and they raised no concerns about working with the service. They told us the management team were responsive and were quick to carry out assessments and complete the necessary paperwork. They said managers were good at coming back to them if they had any queries, and communication had been very good.

The provider did not always understand what being safe meant to them and how to achieve that. During the inspection we had anonymous concerns raised with us about a person’s moving and handling needs, and we raised a safeguarding referral with the local authority and shared the concerns with the provider. The provider took appropriate action to protect the person. However, through the provider’s own investigation, it became apparent that a number of staff were aware of the concerns and the potential risks to the person. Furthermore, all staff involved had failed to escalate the concerns to the management team, so action taken to mitigate the risks was delayed. Following this incident the provider took steps to remind all staff about their responsibility to escalate concerns in a timely manner.

There was a safeguarding matrix maintained to enable the registered manager to track and monitor the progress of any safeguarding investigations. However, there was no lessons learnt process in place to drive improvements and to prevent similar incidents occurring. In addition, there was no system in place for capturing any less serious incidents or concerns about care; this information could only be sought by going into an individual person’s care record. For example, a relative shared with us that concerns had been raised with the office staff about staff cutting care calls short for their family member so they could go on their own social events. However, there was no system in place to capture this information without going into individual care records. In addition, we asked how care concerns were captured that did not meet the threshold for a safeguarding investigation. Again, the provider told us this information would be recorded in the person’s individual record. The provider told us going forward, they would be improving these systems so information could be captured and analysed.

Staff had completed online safeguarding training and told us they would let senior staff know about any concerns and were confident these would be dealt with. However, there was no system in place to ensure the effectiveness of this safeguarding training. Staff meetings were not used as a forum for sharing information about safeguarding outcomes or learning. A staff member told us, “Our training for safeguarding is all online. I know I need to do the safeguarding refresher training. I feel I have some gaps in my knowledge, but I want to be able to do my best.” Another staff member told us that any concerns would be raised with the office staff, and they were confident the concerns would be dealt with.

People reported feeling safe with their regular staff. However, several people and relatives reported concerns about new staff not knowing what to do, not reading their care plan and not knowing how to support them safely. This had the potential to increase the risk of harm to people.

The provider had processes in place designed to enable them to identify and mitigate risks to people; however, these were not always effective. Some care records lacked detail about how people were supported with some health conditions including epilepsy, diabetes and managing the risk of sore skin. In addition, care records lacked detailed about how risks in relation to safe moving and handling practice would be managed. Care records were not always specific, or person centred about the needs of the person being supported. They did not include what the person could do for themselves with support, or if they suffered pain or other discomfort whilst being supported and how their disability impacted on the transfer. It was not always clear or detailed how a person was supported through different moving and handling tasks. This included transitions from lying in bed to sitting up and moving into a position to use a walking aid. Care records for managing behaviours that could cause distress did not include adequate instructions for monitoring, support, or de-escalation, potentially placing people and staff at risk.

Following our inspection, the provider told us they would be providing staff with face to face moving and handling training and also improving records in relation to people’s moving and handling needs’.

The provider took some steps to control potential risks in the care environment. They completed environmental risk assessments within people’s homes during their initial assessment to check if it was safe for staff to carry out care in a safe environment. This included checks around fire safety. However, records did not always give clear information about the safe use of equipment, who was responsible for the maintenance of care equipment and the date this was last serviced. This included hoists and other equipment used to support people with transfers. We asked the provider for this information, and this was provided after our site visit.

People told us staff ensured the home environment was kept safe and free from hazards, before they left. One person told us, “The staff are good. They will mop and hoover and leave things tidy.”

The provider did not always make sure staff were skilled and experienced to carry out their role to provide safe care that met people’s individual needs. Clear oversight of staff training was not in place. Although staff had been provided with an induction which included training and shadowing more experienced staff, there was no system in place to assess staff competence.

The registered manager told us staff had not been trained face to face to use specific moving and handling equipment and had only received online moving and handling training. The provider told us they did have access to a moving and handling trainer but were unable to provide any records regarding what training they had completed with staff and when. Staff confirmed to us they had only completed online moving and handling training.

Staff had been providing support to a person with a complex health condition for several months. Their care plan stated staff would be specifically trained to support this condition.The registered manager and provider told us staff had not been trained and training records seen supported this. They told us and confirmed to us in writing that staff would be trained on 20 August 2025. We acknowledged this. However, after the inspection process the registered manager and provider told us that key staff had been trained the previous year in 2024. It was a concern that the provider and registered manager did not have effective oversight of staff training needs and were not able to provide this information to us at the time of the inspection.

Several people and relatives told us new care staff would often come into their home without knowing what they had come to do, that they did not seem trained or did not know how to support them or their relative effectively. Some people told us staff had not read their care plan. A person told us, “Every time a new staff member starts, I have to tell them exactly what to do. I have to show the staff how to wash me and talk them through everything, and I do get a bit fed up with having to keep repeating it. I have felt safe with most of the staff.” A relative told us, “We do get inexperienced staff at times, and I don't think the new staff get a lot of training.” Another relative told us, “We have one staff member, and they are a gem. When they are not about for any reason, I tend to cancel the care because the quality and experience of the staff they send can be not very good and even after they've been coming for a week with some, they have an inability to learn and they can't understand about the medication and so I'd rather do it myself.”

Recruitment procedures were in place. However, some areas of the recruitment process needed improvement., for example, to ensure there was clear information about staff work history including dates they left past employment. There was also some contradiction in the staff employment contract. The provider told us this would be amended so it accurately reflected the working hours for staff on a sponsorship license.

The provider had a system for monitoring punctuality, duration and staffing of people’s care calls. We raised several queries from the records we looked at regarding the timing and staffing of calls during the month of June 2025. The provider’s own audits had not identified any of these issues. The provider’s electronic call monitoring system did show several ‘alerts’ when a call had not gone as scheduled. However, whilst some of these could be explained, for example a staff member not been able to use their phone to log in, there was often no audit trail to explain the reason for the ‘alert’ and some queries we raised could not be responded to.

Some people reported issues with timings of their visits and 2 of the people we spoke with reported missed calls. A relative told us, “There are 2 regular carers who are pretty good on the time that they come and will phone me if they are running late. The office notifies me if one of the staff is off sick and tell me who will be coming. In the last year they've missed a couple of morning calls, and the evening carer has missed about 3 calls. They were short staffed and didn't send anybody and so I assisted my relative.” Another relative told us, “At the moment things are OK, and we don't really have any problems. The only thing is that we are paying for 45 minutes and often the carers only come for 30 minutes and they arrive 10 to 15 minutes late. We do however feel that our relative is safe with the staff, and they wash them and help them get dressed.”We shared people and relative’s feedback about care call with the provider and they told us there had been no missed calls.

Staff told us they had supervision and could talk with management about their work. They told us spot checks were carried out to make sure they were working to the standards required. Most staff were pleased with the training and support they received. A staff member told us, “I really love my role and feel well supported by the managers. I am very happy with everything.” However, other staff raised some concerns regarding their training. For example, one staff member told us, “I haven’t received any face-to-face training with this provider.” Another staff member told us, “The training is okay, but we do it in our own time, and I need to do some of my refresher training.”

The provider assessed and managed the risk of infection associated with people’s care. People and relatives told us that staff attending their calls would wear appropriate personal protective equipment (PPE). Staff confirmed the appropriate use of personal protective equipment (PPE) was monitored through spot checks by senior staff. Staff had completed training and had access to supplies of PPE.

People generally found the carers to be professional in their appearance with appropriate use of PPE. A relative said, “They do use PPE, and the bin is always full of it. They will even mop the floor and vacuum around.” Another relative told us, “All the carers are clean, fresh, neat and professional looking and come with PPE.”

Some systems were in place for the overview of medicine management. Not all people were supported with their medicines; some were supported by family members and some by staff. Information was not always clear in people’s care records about the nature and level of the support they needed with medicines. For example, in some instances a family member gave the medicines, but staff needed to monitor; however, there was no information about the person’s prescribed medicines and the possible side effects staff may need to be aware of. Some people’s medicine care plan stated staff were not supporting, but staff were directed to apply creams without clear instructions. For some people who staff did support with their medicines, there was a lack of information about how the person should be supported to take their medicines in a way that they prefer. Where there was a specific risk with certain medicines, no risk associated assessment had been completed. This included people who were on blood thinners and there was an increased risk of bleeding if the person had an accident.

A few relatives raised with us they could not always be confident that staff were suitably trained to support their family member with their medicines.

Staff had training on medicines management and staff said this prepared them to manage medicines safely.