Alcester Home Care Agency Ltd Also known as Alcester Primary Care Centre

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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 provider told us they had made recent changes to the staff team to improve the service. The provider felt the service and culture was improving because the staff team now shared the same goals and objectives to provide a safe and caring service. The provider completed audits and reports from their electronic systems to ensure improvements were identified and any learning was taken. The provider told us they were improving aspects of their service by learning. For example, the provider had improved their punctuality and continuity of staff through their own monitoring and by listening to people. The registered manager who was new to the service, had started to identify where they needed to make improvements.

Staff said the safety culture was positive. One staff member said, “We have a no blame culture, a way of doing things without causing issues. We have learning opportunities, and we thrive on that.” This staff member gave an example of how learning from medicines administration recording had been made to make sure people did not run out of medicines.

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 provider’s systems recorded personalised information about risks to people’s health, their medication and wishes for future care. This information in an emergency, could be shared with other health professionals, such as when a person was admitted to hospital. Such information helped ensure people’s pathway to other care settings was smooth. Senior staff explained the provider’s processes for meeting and assessing new people to see if the service could meet people’s needs. This included additional reviews of the care package to make sure, people were happy with the care, continuity and timings.

The provider did concentrate on improving people’s lives to protect their rights for making decisions in people’s best interests. People did live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

Everyone we spoke with felt safe when staff supported them in their own home. One person said, “I do feel safe because they (staff) are all so lovely and whoever is on the list that they send me, it doesn't really matter because they are all so kind and helpful.” A relative told us, “I have never felt that my [Relative] has been unsafe with any of the carers and I'm favourably impressed that they clearly have her best interests at heart.” Another relative told us how they felt the service was safe because, “Staff are respectful of our home and never leave anything around which may be hazardous for us.”

Staff understood their responsibility to keep people safe, protected and their duty to report incidents of poor practice. One staff member told us, “I would report anything to the police because if someone is being assaulted its abuse.” This staff member said regardless of who was the abuser, it would be reported without hesitation. Records showed safeguarding concerns and other safety issues were reported and responded to.

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.

Staff assessed risks to people’s home environment, their safety and welfare. Care plans described the action to be taken by staff to manage those risks. We saw some risk management plans were detailed but others would have benefited from more information. For example, 1 person’s catheter care plan directed staff to change the catheter bag at set intervals. However, care information did not describe the signs of possible infection for staff to look out for. In the person’s care records we could see staff knew what to look for because they had sought advice from a district nurse in early December 2025 due to a discoloration in the person’s urine. Whilst we were satisfied staff had taken the appropriate action, care records needed further information to provide consistent guidance for staff to follow. For another person, their care plan showed staff had implemented additional measures to monitor a person’s bowel movements. However, the person’s care plan had not been updated to show this change.

The provider did detect and control potential risks in the care environment.

The provider ensured that equipment, facilities, and technology supported the delivery of safe care. People lived in their own homes, and the care provider was not responsible for individuals’ personal equipment or the condition of their home environment. However, the provider undertook risk assessments in people’s home to ensure the environment was supportive to deliver safe care and treatment. Environmental risk assessments helped staff to recognise potential hazards when working in people’s homes, including risks to their own personal safety and how to report them.

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.

People and relatives were positive about the staff. Overall, people felt their care calls were on time and for the time duration they needed. A person told us, “They (staff) come 3 times a day or sometimes 4 times a day and are quite flexible around my needs which is often also about whether I'm going out or not. Two carers come on each visit, and they always come in together. We have not felt rushed, and they seem to have plenty of time.” A relative said, “They (staff) come at around the time that we're expecting them or at least within about half an hour. If it's going to be beyond that, they will generally phone to let us know.”

People felt staff knew what to do to help them, although some people felt staff were not always confident with equipment for moving and transferring them. This was because new staff had joined the agency and some experienced staff had recently left. Speaking with new staff, they confirmed they received training on how to mobilise people safely and they had their practice observed through on the spot checks.

Staff said they usually saw the same people so knew them well and they had enough time to provide the support people needed.

The provider had strengthened their recruitment checks by increasing their audit processes to ensure all safe recruitment checks had been completed prior to staff starting with the service. Recruitment checks included staff identity checks, references and Disclosure and Barring Service (DBS) checks. DBS checks provide information about convictions and cautions held on the Police National Computer. This helps providers make safe recruitment decisions. The provider completed ‘on the spot’ checks of staff practice and regular staff supervisions to ensure staff remained safe and effective.

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. The provider assessed and managed the risk of infection.

Staff said they had stocks of personal protective equipment (PPE) and they understood when to us their PPE to minimise cross infection risks. One staff member said, “We get gloves, aprons, uniforms, boxes and boxes of them. I use not just a pair of gloves for 1 visit. I use gloves for personal care, then change them when I am dressing someone and then change my gloves again if I prepare any food.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People told us they received their medicines and relatives were satisfied their family members received medicines from staff at the times prescribed. In some cases, relatives supported their family members with their medicines or people were able to administer their own medicines. Nobody raised any concerns when staff administered their medicines.

However, we found improvements were required in the way some people’s medicines were administered and recorded. Whilst we found people had not come to harm, we could not be confident those people received their medicines safely and as prescribed. For example, patch medicines for pain management were not applied correctly to the skin. When a medicated pain patch is not applied as directed, it may not deliver the right dose of medication, potentially leading to a loss of pain relief or, in some cases, an overdose. The registered manager told us they had identified this issue 2 months ago and had implemented charts for staff to record where patch medicines had been applied. We spoke with 2 senior staff and neither of them knew the safe frequency of rotation for this medicine. We also spoke with a staff member who recently administered this medicine, and they said they did not complete any paper or electronic patch charts. Processes to make sure people received their medicines were completed, such as audits and to limit medicine errors at the earliest opportunity. However, these were not always effective in identifying the issues we found.