Holistic Care UK

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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 this inspection the rating is Requires Improvement. This meant people were not safe and were at risk of avoidable harm.

We found the provider to be in breach of 3 legal regulations relating to safe care and treatment, safe and effective staffing and fit and proper persons

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A system was in place to report, record and monitor incidents and accidents, the provider told us that they had not had any accidents or incidents, since the last inspection.

The provider told us that they shared learning with staff during team meetings. However, when we reviewed staff meeting minutes for July, August and September 2025, we did not find any evidence that organisational learning or best practice in relation to clients was shared with staff.

The provider did not have effective systems to ensure continuity of care. We saw that people with cognitive impairment did not have a ‘hospital passport’ in place. A ‘hospital passport’ would include important information for other health professionals about the person and their health needs and preferences, should the person be admitted to hospital.

There were systems in place to safeguard people. The provider told us they had not had any safeguarding incidents since the last inspection in 2014.

One relative told us that they felt safe and with the support they received from care staff, “[Staff] accompany [my family member] to make sure they are safe.”

Safeguarding policies and procedure were in place and staff had undertaken safeguarding training. There had not been any safeguarding concerns, however, there was an effective system in place to safeguard people appropriately and manage concerns of abuse.

People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse. Staff had training on how to recognise and report abuse, and they knew how to apply it.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe and supportive.

Risks to people’s health and safety were not assessed, adequate or mitigated. This included Parkinson’s disease, dementia, diabetes, medicines mobility and falls, communication, environment and fire.

Mobility and falls risk assessments did not always identify the mobility aid people used, or the risks linked to aids such Zimmer frame, walking stick and shower chair.

We found there were risk management plans for people’s specific health conditions such as Parkinson’s disease, dementia and diabetes were not in place or were ineffective, as not all staff knew how people’s health conditions affected them or how to reduce associated risks.

The provider was not aware that one person was living with Parkinson’s disease and that both people whose care plans we looked at were living with dementia. People who lived with dementia did not have risk assessments and management plans in place. The provider failing to assess individual risks to people in relation to their health conditions meant that both the provider and staff did not understand the conditions people lived with and how to safely support them, which placed them at the risk of avoidable harm.

Staff we spoke with did not know that one person lived with dementia and lacked understanding of dementia types and how these impacted people. There was no information for staff on how this condition impacted people as individuals, the risks associated with their condition, how to mitigate the risks and support them safely. When staff were asked about people they supported with dementia, one staff member said, “No [person] does not have dementia”.

When we spoke to the provider about the two people who had been diagnosed with dementia, they told us, that they did not agree that either person had dementia. We raised concerns that both people had a diagnosis of dementia, but we were not provided with assurances that they would rectify this and implement care plans and risk assessments for people living with Parkinson’s disease, dementia, diabetes and mobility aids.

The provider did not detect and control potential risks in people’s homes. Fire risk assessments were not in place, including guidance for staff on what to do in the event of an emergency. There was no information about how people could access support and help in the event of a fire in their home if a staff member was not present. For example, having a phone close by to call emergency services or a call pendent.

We discussed these concerns with provider, who was not aware of this shortfall. This meant the provider had failed to ensure that robust person-centred fire risk assessments were in place with guidance for staff on the actions to take in the event of a fire.

Recruitment practices were not robust, and procedures had not been applied consistently across the service. As a result, there was a risk that people could receive care from staff whose suitability and good character had not been fully established before they began working.

When we reviewed four staff files, we found that Disclosure and Barring Service (DBS) checks had not always been completed prior to employment. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. Providers must be able to demonstrate sound reasons for not obtaining a full DBS check before a person takes up post and also demonstrate they have assessed any potential risk. In three cases, the provider had accepted DBS checks completed by previous employers rather than obtaining new ones. One person had a DBS from a previous employer dated August 2023, although they did not start working for Holistic Care UK until August 2024. The second person’s DBS was dated June 2024, and they started work in November 2024. The third person’s DBS was dated July 2020, and they started work in December 2024. For all 3 staff members, there were no reasons recorded as to why a full DBS check could not be obtained by the provider and potential risks assessed.

Our review of staff files also showed that the provider had not consistently secured the required two satisfactory references before staff started work. The provider’s own policy stated that two references were necessary, one of which must come from the current or most recent employer. However, two staff members had only one reference on file, and in one case a reference was obtained two days after the individual had already begun working. In addition, three staff members had references from people not listed as referees on their application forms. We were not assured that employer references were reliable. They were not submitted on headed paper and were without a company stamp. Application forms were also incomplete, with three containing unexplained gaps in education or employment history.

Records confirmed that staff were not receiving supervision at the frequency required. The supervision policy stated that staff should be supervised every two months, yet two staff members had only one supervision in the past year, while the remaining two had only two supervisions.

Although the provider used methods such as competency assessments and spot checks, we could not be assured of their effectiveness. One staff member had no spot checks at all during the previous year, and three had spot checks that were incomplete or lacked essential details such as dates or signatures. Additionally, competency assessments for administering medicines had not been completed for three staff members.

We saw the provider had infection control policies and procedures in place and staff received training in infection prevention and control. There was appropriate personal protective equipment (PPE) available for staff to use when delivering personal care. One relative told us that staff always wore PPE, they commented,“The carers always wear gloves when doing any personal care”.

Medicines were not safely managed. One person’s care plan recorded that they were living with dementia and required ‘prompting and supervision’ with their ‘as required’ (PRN) medicines. The provider was unclear about the level of support this person required with medicines. Initially, they told us that staff only reminded the person to take their medicines but later stated that staff did administer medicines. When staff were asked about this person’s medicines, their responses were inconsistent. One staff member stated that the person self-administered their medicines but then said that staff sometimes administered medicines as the person could forget.

The PRN Medicine Administration Record (MAR) for the period September to December 2025 showed only one entry for PRN administration, dated “03/25.” The date was not written in full and appeared to refer to March 2025. However, the person had not joined the service at that time. The provider was unable to confirm the exact date on which this PRN medicine had been administered. As a result, we could not be assured that people were receiving their medicines as prescribed.

For another person living with Parkinson’s disease, the provider told us that their medicines were time critical and were managed entirely by family. Time-critical are medications that must be given at precise times to prevent serious harm or loss of treatment effectiveness. However, the person’s family, told us that staff administered lunchtime medicines. Staff told us that they administered lunchtime and teatime medicines to the person. This person’s medicines risk assessment did not reflect that both staff and family members administered medicines, and the associated risks had not been assessed.

Medicine Administration Records (MAR) confirmed both staff and family members administered medicines, including a ‘time-critical’ medicine for Parkinson’s disease. Time-critical medicines are medications that must be given at precise times to prevent serious harm or loss of treatment effectiveness.

Dates of administration were inconsistently recorded. The MAR for this medicine stated, “One tablet twice a day plus (8am and 12pm)”. However, we found entries showing administration on 4 August 2025 at 4:30pm and at 9pm on a daily basis. We were not assured that medicines were being administered safely, that the provider understood the person’s medicine needs, or that people were protected from potential harm.

Diabetes risk assessments did not include information on how to recognise symptoms of high or low blood sugar, nor did they outline the actions staff should take to respond appropriately.