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ACAH Limited Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 11 March 2020

About the service

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

Not everyone who used the service received personal care. The Care Quality Commission (CQC) only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of inspection 23 people were being supported with personal care.

People’s experience of using this service

The systems in place to monitor the quality, safety and performance of the service were not always effective and were not consistently maintained.

Risks to people’s care were assessed but there was a lack of detailed information for staff to follow to mitigate the risk identified. Staff training had not been regularly refreshed to ensure they followed best practice and they did not benefit from regular supervision and opportunities to get to together to share experience and good practice.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; however, the policies and systems in the service did not fully support this. Staff had not undertaken up to date training around the Mental Capacity Act.

People were cared for safely and staff understood their responsibilities to keep people safe from abuse or harm. They received their medicines safely and there were effective practices in place to protect people from infection.

Staff were kind and considerate and had developed positive relationships with people. They arrived on time and were consistent in their approach.

People had individualised care plans which ensured they received person-centered care. Care plans included people’s preferences, their likes and dislikes and their diverse needs.

The provider was open and honest and listened to people, taking action when necessary.

For more details, please see the full report which is on the CQC website at

Rating at last inspection:

The last rating for this service was requires improvement (8 February 2019).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified a continued breach in regulation in relation to the governance and management of the service at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority and clinical commissioning group to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 11 March 2020

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 11 March 2020

The service was not always effective.

Details are in our effective findings below.



Updated 11 March 2020

The service was caring.

Details are in our caring findings below.



Updated 11 March 2020

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 11 March 2020

The service was not always well-led.

Details are in our well-led findings below.