Baobab Care UK Limited

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 4 legal regulation in relation to inadequate care planning and risk assessing and unsafe medicines and finance management; protecting people from abuse and harm; staffing; and fit and proper persons employed at this service.

This service scored 25 (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. Opportunities were missed for learning to continually identify shortfalls in safety in the service and embed good practice.

The culture within the service was not focused on improving safety and learning.

There was a new system in place for recording and analysing incidents however, the provider failed to ensure the identified actions had been carried out. This meant we were not assured opportunities to drive improvements in the service would be made and lessons learnt in relation to incidents which occurred. The registered manager could not demonstrate that this delegated task was being carried out by a staff member who had been trained and assessed as being competent to do so.

We found a lack of consistency in raising safeguarding alerts following incidents. Where safeguarding incidents had happened, there was a lack of investigation and detailed analysis.

Staff supervisions were not carried out regularly for all staff to aid improvements in the service and safety of people in relation to their support needs. Staff told us they could speak with the registered manager, or other senior team members should they wish or need to about any concerns they had.

The registered manager told us, they did not have a list of complaints however, the provider shared a complaints tracker with us. We found that the recording and analysis of complaints was not robust there was no evidence that outcomes were used to improve the service or that any changes were cascaded to staff.

People and relatives told us they could contact the service if they had any concerns about their care. However, feedback was mixed about how the provider responded to complaints. Two relatives told us they had stopped raising complaints as they were either simply not responded to or actions were not taken to improve the service received.

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

The provider had moved some people between different locations and services without consideration of people’s choice or preference. Where people did not have the capacity to make their own decisions the service had not supported them to do so by using the 5 principals of the Mental Capacity Act (MCA) nor had they sought support from people’s families or representatives or involved other professionals in the decision.

Care plans and risk assessments held by the provider failed to demonstrate there was adequate information for robust continuity of care, including when people moved between different services. This included when people transferred to hospital due to their health conditions having deteriorated. The Positive Behaviour Support (PBS) and safety intervention plans were unclear and did not provide appropriate guidance for staff on how people expressed their distress or anxiety; how staff should support them to de-escalate before reaching a crisis situation; and, how staff should safely respond in a crisis situation.

We found support plans in place which had been uploaded to the provider’s electronic system, were inadequate for staff to refer to should they need guidance. The provider had not taken into consideration the implications of staff not having access to complete information online.

The provider had completed an assessment of needs prior to providing support however, these documents lacked sufficient information in relation to the support people required, health conditions and life histories. Staff we spoke with were not aware of all of the health conditions people had or their life histories. This meant staff did not have significant and important information available to them.

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 abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

At this assessment we found the provider failed to adequately protect people from potential harm. The provider had failed to seek further advice and put appropriate measures in place, to ensure the safety of people who were at increased fire risk in all 5 supported living locations we visited. We also found environmental concerns in all 5 locations which had the potential to cause harm or injury. This lack of action could have caused significant harm or even death, because guidance for staff to follow and safety equipment was not in place.

This placed people at risk of harm or injury due to the lack of guidance for staff.

The provider had not reported or sought support from other professionals when people had been absent from the service for prolonged periods of time. Putting vulnerable people at risk of harm. This was despite the provider having policies which gave clear guidance on actions they should take when safeguarding concerns arise and in relation to a missing person.

We reported 12 concerns that had not been identified by the provider to the local authority safeguarding team.

Not all staff members employed had received training in safeguarding. We saw that only 53 of the 83 staff had completed the training.Staff we spoke with could tell us what the signs of abuse were and how to protect people and raise safeguarding concerns.

Most people told us they felt safe with the staff supporting them.

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.

At this assessment, we found insufficient risk assessments and guidance for people who needed assistance to manage their daily living and support them with good mental health. This included a lack of clear guidance on who else is involved in planning of their care and how to support people safely and manage any identified risk. Support plans and risk assessments for other known risks, such as smoking, fire risks, diabetes management and asthma had not been developed to ensure people were safe. Not all known risks had been assessed or identified, there was no guidance for staff about how the risk should be managed, which had the potential to put people at increased risk of harm.

There was a lack of effective systems, processes and guidance for staff in relation to the management of known risks to people. Further information for staff was needed about how the risks would be managed. Despite this, staff told us they felt there was enough information to provide safe care.

Four of the five relatives/representatives told us they had not been involved in managing risks or been shown any risk assessments. This included those who had Power of Attorney (POA) for making decisions on behalf of people. This does not reflect an inclusive approach to risk management.

Despite our findings there was no evidence people had been harmed. Staff knew people’s needs and told us they understood how to manage people’s care in a safe way.

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

The provider failed to carry out comprehensive environmental risk assessments of people’s homes and provide associated guidance for staff to follow. For people who smoked there was a lack of suitable risk assessments in place to mitigate risks associated with smoking and reduce the potential for harm to both the person and staff.

The provider had commissioned 4 fire risk assessments in April 2026 however, we found the provider had failed to complete identified actions. This was a significant concern as many of these actions were deemed to be of an ‘Intolerable Risk’ and as such works should be completed within 24-72 hours with a maximum of 7 days if interim controls were applied. The provider had failed to escalate these to the landlords to carry out the required actions in a timely way on behalf of the vulnerable people they supported.

There were personal evacuation plans in place to guide staff on individuals’ needs in the event of a fire. However, these needed further information to ensure people with sensory impairments had adequate support and equipment to alert them in the event of a fire.

In all 5 locations we visited, we found multiple areas which were poorly maintained and posed a risk of harm due to sharp edges, broken equipment and trip hazards. The provider failed to identify and take steps to control potential risks within the environment care was delivered.

Due to the level of concerns in relation to the environment and fire risks referrals were made to the local safeguarding team, commissioners and West Midlands Fire Service (WMFS).

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 failed to ensure there were always enough staff to support people as per their assessed and commissioned hours to ensure they were supported safely. We found when visiting 1 service where a person required 1:1 support and another required 2:1 support, only 2 staff were present instead of the required 3 staff. We were told the third staff member was supporting another person to attend an appointment. We were at the location for over 2 hours and the third staff member did not return. This placed both service users and staff at significant risk of harm.

People and relatives told us overall they were happy with the times staff supported including the length of time staff were there. However, the provider failed to operate a robust system to ensure staff were providing support at the times people required. One relative told us how a staff member was late attending their loved one’s home at times which resulted in the person experiencing increased anxiety. This did not reflect an effective system to ensure staff attend the calls at the correct times. This placed people at risk.

Whilst shadowing records were not detailed, staff members told us they had the opportunity to shadow experienced staff members. This shadowing was designed to help them get to know the person’s care needs prior to working unsupervised. Most people or their relatives told us they had consistent staff members however, 1 person told us, “[Name] care staff member is great but new staff are not good and they could improve their attitude. I don’t feel they understand my needs.”

The provider's recruitment systems were inadequate, and safe recruitment practices were not always followed. People were at risk of harm from receiving care and support from unsuitable staff.

Suitable references had not been obtained for many staff members whose recruitment files we looked at. References had not always been obtained from prospective staff's most recent employer or provided by people who had not been named as a referee on the staff member’s application form. This meant the provider had failed to ensure they had obtained all the information required ensuring the suitability of all staff employed. Where this had occurred, the provider failed to carry out a risk assessment to mitigate the potential risks this may pose. This placed people at risk as the provider did not know if staff were suitable to support vulnerable people.

We found from records provided to us that 20 of the 83 staff employed did not have a Disclosure and Barring Service (DBS) check completed prior to staff commencing employment. Staff member’s records demonstrated they had gone into people’s homes to carry out shadowing duties and lone working without a DBS check in place. Some of whom had done so for several months. The provider had failed to carry out any risk assessments in relation to this practice. The DBS provides information about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. The provider had since obtained DBS checks however, during our assessment we identified 1 staff member who was currently working at a person’s home who had no references, DBS check or application form.

In addition, we found a widespread failure by the provider to evidence they had explored any gaps in employment records.

The training matrix indicated most of the 83 staff had not received mandatory training and there were no robust competency assessments in place to demonstrate staff learning following the completion of on-line training. This meant the provider could not be assured staff had learnt and had the knowledge and skills to carry out such support. We found where specialised care equipment was in place, staff had not always been appropriately trained in the use of this.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider failed to operate effective infection, prevention and control in their supported living locations. We found in all 5 services where the was communal living spaces such as; lounges, kitchens and bathrooms these were very dirty or had damaged furniture, flooring and paintwork which prevented effective cleaning. The staff and provider told us they did not have any cleaning schedules for these areas to demonstrate a robust approach. This placed people at risk from cross infection. The provider told us following us raising these concerns that he had arranged for a deep clean of the services to take place.

The registered manager and provider were unable to provide any evidence to demonstrate they carried out spot checks to ensure care staff were following safe practices and were adhering to the correct use and safe disposal of personal protective equipment (PPE).

Staff told us they had access to the PPE they needed to prevent and control the spread of infection and had received training. We observed staff wearing PPE as required.

The providers infection prevention and control (IPC) policy was not easily accessible to staff for them to refer to. This meant staff did not have access to clear information and guidance on IPC measures in place and the provider had not robustly implemented this guidance in the day-to-day support plans for people.

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

We found people were not always supported to receive their medicines in a safe way. We found shortfalls in the safety of medicines management at this assessment.

Storage of medicines and the key safety was poorly managed, keys to access people’s medicines were not stored securely. We found keys to access storage areas we either hung up on the wall or in unlocked cupboards or pots on a desk. This meant any unauthorised person could have access to these as could people living at the services. The provider told us they had taken action to improve the key safety in all services.

We also found that cupboards or rooms where medicines were stored did not all have locks, which reduced the security of stored medicines.

People were not offered the option of having their medicines stored in their own rooms. All medicines were stored in a central location which was only accessible by staff. This is not in line with best practice where supporting people with a learning disability or autistic people.

However, 1 person was supported by staff to access the medicines cabinet, but the provider had failed to provide staff with clear guidance or suitably risk assessed this practice.

Care plans and risk assessments contained little or no information to guide staff on the level of support people needed with their medicines. There was also a lack of information for staff members to follow for the administration of 'as required' (PRN) medicines, to ensure a consistent safe approach. This included the application of people’s prescribed creams by staff and medicines used to relieve anxiety or distressed responses. Protocols and guidance for PRN medicines were not in place, and this was confirmed by the registered manager and provider. Without clear protocols in place, staff did not have clear instruction of when to give these medicines, leading to the potential for too much or too little medication to be given.

We found some people who had prescribed medicines with no Medication Administration Record (MAR) in place. This meant there was a risk of staff not being aware of these prescribed medicines, resulting in people not receiving their required medicine.

We also found discrepancies in the actual number of medicines in stock against what should be. This meant we could not be assured people received their medicines as prescribed.

Most people and their relatives told us they had no concerns with the support they received with their prescribed medication.