Ryedale Homecare

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 requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to governance. Enough improvements were not found at this assessment, and the provider remained in breach of this regulation. However, the provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found during this assessment, and the provider was no longer in breach of this regulation.

This service scored 59 (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 always have a proactive or positive learning culture. Systems to identify, review or learn from safety concerns were not well established. Although people described staff as kind and supportive, this did not translate into a learning culture at organisational level. Management had not acted on previously identified areas of non-compliance, and improvements were not sustained. The registered manager acknowledged a lack of auditing and oversight, with the service heavily reliant on staff communication rather than structured processes to identify changes in people’s needs or emerging risks. Oversight of daily records was limited, and care logs were not routinely reviewed despite changes in people’s needs.

Environmental home risk assessments were not completed. Some people had no risk assessments in place, even where they required support with mobility, personal care, or specific health needs. This reflected a failure to embed learning from previous assessments, where similar issues had been raised.

The provider did not always maintain safe systems of care. Continuity and safety were reliant on staff familiarity with people rather than structured systems, and the provider did not always manage or monitor people’s safety effectively.

Staff did not have essential information about safety within people’s homes, as risk assessments had not been completed.

Several people had only an initial assessment of need, with no associated care plans or risk assessments, despite receiving personal care for weeks or months. This included individuals with dementia, continence needs, and mobility or health‑related risks, meaning safe pathways of care were not consistently established. Management oversight of care information was limited. Care logs had not been routinely reviewed, potentially preventing the service from identifying changes in people’s needs or adjusting care in response to emerging concerns.

Safeguarding processes were generally effective. Staff understood how to identify and report concerns, and records showed that safeguarding matters were logged, investigated and followed up where appropriate. The safeguarding file included evidence of liaison with external agencies. This included a police notification which had been reviewed with documented actions and resulting outcomes.

There was no safeguarding concerns identified in people’s feedback or during observations, and people felt safe and well‑supported. Staff interactions with people, including those with a learning disability, demonstrated awareness of people’s needs, communication preferences and wellbeing.

The provider did not always work well with people to understand and manage risks. Some people had no risk assessments in place, despite receiving regulated activity and support with mobility, continence, dementia and health‑related needs. This meant they were not consistently involved in identifying or managing the risks associated with their care.

For some people, only an initial assessment of need had been completed, and essential person‑centred information such as communication needs, preferences and support guidance was not fully captured into working care plans. This limited the provider’s ability to involve people meaningfully in discussions about how best to manage their safety and wellbeing. Care logs had not been routinely reviewed, meaning the service did not always identify changes in people’s needs, or seek their views on adjustments required to keep them safe.

People described positive relationships with staff during feedback and site visits. However, these interactions were not always supported by structured processes to involve people in risk assessment or supporting them to make informed decisions about their care.

The provider did not always detect and control risks within the care environment. At the start of our assessment, environmental home risk assessments had not been completed for any person This meant the provider and staff did not have essential information about environmental hazards in people’s homes, or how these should be managed to support safe care delivery. This meant staff were not consistently supported to take appropriate precautions in relation to risk.

Although environmental risk assessments were later completed for 3 people following our feedback, this demonstrated reactive rather than proactive risk management and did not provide assurance that environmental safety was consistently monitored across the service.

The provider did not always ensure there were enough staff with the right skills and knowledge to deliver safe care. While recruitment checks were completed and staff files contained DBS certificates, references, induction records and performance reviews, competency checks were limited and had only been completed for medicines. Other competencies, such as moving and handling had not been completed. However, following this inspection the provider confirmed this was something they had implemented.

Training records showed staff had received a range of mandatory courses; however, oversight of ongoing competency and practice was not robust. The service remained reliant on staff communication rather than structured supervision or observational checks to assure safe practice.

There were no concerns about staffing numbers during the assessment, and no agency staff were used. However, the lack of systematic oversight of staff competence meant the provider did not always ensure they always followed best practice guidance needed to deliver consistently safe care.

Training records showed staff had completed infection prevention and control (IPC) training as part of their mandatory training requirements, indicating they had the basic knowledge needed to apply safe practice. Staff files also confirmed that IPC formed part of individual training matrices and competency expectations.

There was no IPC concerns identified during the assessment. Daily logs and general charts for people receiving personal care showed staff were delivering routine hygiene, positioning and skin‑related tasks appropriately, with no recorded concerns about infection risks in people’s homes.

Although formal auditing of IPC was not evidenced in the notes, observations of practice, staff training and the absence of identified infection‑related issues indicated these risks were managed to an acceptable standard.

Medicines were managed safely. Staff competency checks for medicine administration were in place and up to date. The most recent competency review was completed in February 2025, with the next due in February 2026.

Medicine Administration Records (MAR) were consistently completed with no gaps or omissions, and included appropriate sections for refusals, PRN (as required) use and topical medicines. Reviews of individual MARs confirmed accurate recording, clear personal details, GP information, allergy status and special administration requirements. For people with a learning disability, MARs included clear guidance to support safe administration.

There was evidence of medicines‑related risk assessments within care plans, including choking risks, hydration risks, seizure‑related risks and medication‑specific considerations. Staff demonstrated an understanding of people’s needs, and medicines were stored and administered safely as part of daily care tasks.

Overall, systems supporting medicines optimisation were effective, and medicines were safely managed throughout the assessment.