During an assessment under our new approach
Date of assessment: 15 May 2026 to 16 June 2026.
The service is a domiciliary care agency providing support to adults living in their own homes. Not everyone using the service received personal care. The Care Quality Commission (CQC) only assesses where people receive personal care. Personal care includes support with tasks relating to personal hygiene and eating. Where people received personal care, we also considered any wider social care provided. At the time of our assessment, 30 people were receiving the regulated activity.
There was a registered manager in post at the time of this assessment.
We identified breaches of regulations relating to safe care and treatment, consent and good governance. We also found the provider had not ensured their Statement of Purpose accurately reflected the regulated service being delivered. As a result of the concerns identified, we have asked the provider to submit an action plan detailing how they will address the areas requiring improvement.
The provider was supporting people whose needs were not reflected within their Statement of Purpose. This meant they could not demonstrate that all aspects of the service being delivered had been considered within their registration arrangements.
We assessed the service against the principles of Right Support, Right Care, Right Culture. The service was not always able to demonstrate these principles were consistently met. Although people generally received kind, caring and personalised support from staff who knew them well, significant weaknesses in governance, risk management, care planning and oversight arrangements reduced assurance that care was consistently planned, delivered and reviewed in line with people's needs and preferences.
People, relatives and professionals consistently described staff as caring, compassionate and committed to supporting people's wellbeing. People valued the positive relationships they had developed with staff and told us they felt respected, listened to and supported to maintain their independence. Professionals described the service as responsive and flexible and told us staff worked positively alongside health and social care partners to support people.
However, systems designed to assess, monitor and manage risks were not effective. Risk assessments and care plans did not consistently contain sufficient information to support the safe management of people's needs. We identified concerns relating to the management of complex healthcare conditions, including dysphagia, PEG care, diabetes, epilepsy, severe allergies and the use of emergency medicines. Care records did not always provide staff with clear guidance on managing identified risks, recognising deterioration or responding appropriately during emergencies. This placed people at risk of receiving unsafe care and avoidable harm.
The provider's governance and quality assurance systems were ineffective. Audits were not routinely completed, and existing oversight systems had failed to identify a range of concerns found during the assessment, including shortcomings in risk management, care planning, medicines management, consent processes, safeguarding oversight and record keeping. Leaders relied heavily on an electronic recording system and staff knowledge; however, they had not ensured records were sufficiently detailed, person-centred or reflective of people's current needs. As a result, leaders could not demonstrate effective oversight of quality, safety and outcomes.
Medicines management processes did not always reflect best practice. Information relating to medicines prescribed on an as-required basis did not consistently provide staff with sufficient guidance to support safe administration. Medicines audits had not identified these concerns, reducing assurance that medicines systems were operating effectively.
The provider did not consistently follow the requirements of the Mental Capacity Act 2005. Mental capacity assessments and best-interest decision-making processes had not always been completed where required. The provider was also unable to demonstrate consent had consistently been obtained for the use of people's photographs on social media. This reduced assurance that people's rights, choices and autonomy were always protected.
Staff received training, supervision and competency assessments to support them in their roles. Appropriate recruitment checks were completed before staff commenced employment. Staff demonstrated a good understanding of people's needs and spoke positively about the support they received from leaders and colleagues.
The provider was open, honest and responsive throughout the assessment. Leaders acknowledged the concerns identified and took immediate action in response to feedback. However, the concerns identified during the assessment demonstrated that systems for governance, oversight, risk management and continuous improvement were not effective. Significant improvements were required to ensure people consistently received safe, well-managed and person-centred care.