Allot Healthcare Services York

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 changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, staffing, and fit and proper persons employed.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider did not have a positive learning culture. Governance systems were ineffective and leaders could not demonstrate that incidents, complaints, safeguarding concerns and quality information were consistently reviewed, analysed or used to improve practice. Repeated concerns relating to staff timekeeping, continuity of care and communication continued to be identified through audits, complaints, staff feedback and people's experiences, with limited evidence that lessons had been embedded. For example, audits, complaints reviews and staff meetings repeatedly identified concerns regarding timekeeping, continuity of care and communication. Whilst actions were recorded in response, inspection findings showed these issues continued to be experienced by people and relatives, indicating lessons had not resulted in sustained improvement.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

Systems to ensure safe care delivery and continuity of support were not effective. The service had experienced fragmented systems and ineffective contingency arrangements, resulting in gaps in oversight and difficulty locating important records. We found inconsistencies between care plans, electronic records and paper documentation, including risks, allergies and important health information not always being reflected consistently. Relatives repeatedly raised concerns regarding poor communication, inconsistent carers and delays to care calls.

This placed people at risk of receiving unsafe or inconsistent care because staff did not always have access to accurate, up-to-date information about people's needs, risks and support requirements.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider did not operate effective safeguarding systems and could not demonstrate people were consistently protected from the risk of abuse. Safeguarding concerns were not always recorded, monitored or reviewed through governance systems. For example, 6 safeguarding notifications submitted to CQC in July 2026 were not reflected within incident logs or accident and incident audits. Records reviewed identified additional concerns that injuries and incidents had not been escalated due to management oversight processes. The provider could not demonstrate they consistently learnt from safeguarding concerns or took effective action to reduce future risk. There were discrepancies between safeguarding information held by the provider and partner agencies, alongside ongoing concerns about staff knowledge, communication, continuity of care, and the provider's ability to identify and respond to emerging risks. This meant people were not protected by robust safeguarding oversight and systems.

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, supportive and enabled people to do the things that mattered to them.

Although care plans were often detailed, they were not always current, consistently implemented or accurately reflected in the electronic information available to staff. Risks such as seizures, falls, skin deterioration, nutrition, bowel health and pressure care were not always recognised, escalated or reviewed effectively. Care records identified concerns including wounds, pressure damage, seizures and changes in wellbeing that had not been recorded on incident logs or incorporated into risk management arrangements. For example, care records for one person identified a fresh wound to their head and three health related episodes on the same day. However, these concerns had not been recorded within the provider's incident management systems and there was no evidence they had been reviewed through governance processes. Monitoring records were incomplete, poorly organised and showed gaps in oversight. Some people and relatives raised concerns about staff knowledge, continuity of care and unfamiliar staff delivering support. This meant we could not be assured risks were consistently identified, reviewed and managed in partnership with people to maintain their safety and wellbeing.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

People's homes were assessed and care plans included environmental risks, equipment requirements and emergency information. Detailed risk assessments were available for areas such as moving and handling and emergency evacuation. However, monitoring systems for environmental and equipment-related risks were not effective. One of the registered managers acknowledged records held in people's homes had not been routinely reviewed, which meant they could not be assured environmental and equipment-related risks were consistently identified and managed to keep people safe.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider could not demonstrate there were enough suitably recruited, trained and competent staff deployed to meet people's needs safely. Significant discrepancies were identified between staffing records, recruitment records, training records and staff working within the service. The provider was unable to provide accurate information about staff numbers and could not demonstrate effective oversight of recruitment, training compliance or staff deployment following ineffective contingency arrangements. Staff training records contained substantial gaps, including examples of staff working alone or on care packages despite large numbers of mandatory or specialist training courses not being completed or evidenced.

The provider could not be assured staff had the knowledge, skills and competencies required to support people safely. Inspection findings identified concerns regarding staff training relevant to people's specific needs, inconsistencies in recruitment records, gaps in employment histories, expired or unavailable checks, and examples where staffing arrangements contributed to concerns about continuity of care. People and relatives also raised concerns regarding unfamiliar staff, staff knowledge and inconsistent care delivery. For example, one relative told us, “Some (staff) do not have a clue how to use them”, when referring to a simple piece of equipment. These failings meant systems were not effective in ensuring sufficient numbers of suitably skilled, competent and safely recruited staff were available to provide safe care.

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 received infection prevention and control training and care plans included guidance relating to skin care, catheter management, continence care and use of personal protective equipment. Staff told us they had access to personal protective equipment and we observed supplies stored within the office. Audits and meetings also demonstrated infection prevention and control was routinely discussed. However, concerns remained regarding oversight of staff competencies and control measurements for infection prevention and control.

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

Records reviewed during the inspection identified inaccuracies, incomplete documentation and inconsistencies between care plans, medicines administration records and care notes. For example, one person’s medicine administration record (MAR) had medicines recorded as administered on a date which did not exist. Medicines-related incidents and refusals were not always clearly recorded, escalated or reviewed, and the provider could not demonstrate effective oversight of medicines management. Audits identified recurring concerns regarding medicines refusals, documentation and medicines stock management, indicating previous actions had not been fully effective in reducing risks.

The provider could not demonstrate staff had received all training and competencies required to support people with their medicines safely. Training records showed gaps in both mandatory and specialist medicines-related training, including for staff supporting people with complex needs. This meant the provider could not be assured people consistently received safe and effective support with their medicines.