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Archived: Atlas Care Services Ltd Wisbech Inadequate


Inspection carried out on 30 December 2019

During a routine inspection

About the service

Atlas Care Services Ltd Wisbech is a domiciliary care agency providing personal care to people in their own homes. At the time of the inspection 113 people were receiving a service. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

People’s experience of using this service and what we found

There was a continued lack of provider oversight of the service, in spite of the enforcement action we took following our last inspection. People’s health, safety and welfare continued to be at risk because the provider did not have effective systems in place to assess, monitor and improve the quality of the service. Ten of the 11 people/relatives we contacted told us they were not satisfied with the service they received. Staff continued to not be deployed effectively, which meant that care calls were frequently late, did not always last the correct amount of time and some people received care from a high number of different staff.

The provider had failed to manage safety effectively, which placed people at risk of harm. Risk management was not robust enough to ensure staff knew how to minimise risks to people. Safeguarding policies and procedures were not always followed, putting people at risk of abuse. Staff did not always have the training or support to carry out their role in line with current good practice.

People’s care plans had not all been reviewed or kept up to date so there was a risk that people did not get the care they needed in the way they preferred. Complaints were not always responded to and not addressed.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

We have made a recommendation about involving people in decisions about their care.

Some improvement had been made since our last inspection in that there had been far fewer missed calls. People spoke highly of the staff who provided their care and were satisfied with the way staff gave them food and drink.

During our first site visit there was a registered manager in post. They resigned from their post before the inspection was concluded.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was inadequate (report published 10 September 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

This service has been in Special Measures since our last inspection. During this inspection the provider demonstrated that not enough improvements had been made and they remained in breach of regulations. The service is rated as inadequate overall and in three of the key questions. Therefore, this service remains in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

The provider had appointed senior staff to oversee and improve the service. However, they had been in post for three months but had not addressed and rectified the shortfalls we found at the last inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Atlas Care Service Ltd Wisbech on our website at


We have identified breaches in relation to complying with regulations; governance; staffing; safe care and treatment; person-centred care; complaints; and

Inspection carried out on 15 March 2019

During a routine inspection

About the service: Atlas Care Services Ltd Wisbech is a domiciliary care agency. It provides personal care to people living in their own homes. It provides a service to older and younger adults. At time of the inspection a service was being provided to 149 people.

People’s experience of using this service:

Risks to some people were not always managed safely. Risk assessments did not always identify what the risk was, or the action staff should take to reduce the risk. Risks to people were also increased because not everyone using the service had a care plan and for those who did, they were not always accurate.

People did not always receive visits from the care staff at the correct time. Some visits were late, and some did not happen at all. The provider had systems in place to prevent late and missed calls, but the management of the systems were not effective. This placed people’s health and safety at risk.

People’s medicines were not always managed safely. Not all medication administration records (MARs) had been completed accurately. Audits had not identified all issues with the MARs and where issues had been identified action had not always been taken in a timely manner. People were at risk of not receiving their medicines as prescribed.

Staff received an induction and shadowed a more experienced staff member when they started their employment. Staff lacked direction because they were not fully supported or supervised. Not all staff had a good understanding of the principles of the Mental Capacity Act 2005. This meant that staff may make decisions on people’s behalf (when they lacked capacity to do so) without following the correct procedures.

Care plans provided by the local authority were in place. However Atlas Care Services Ltd Wisbech had not always completed their own care plans or reviewed the local authority care plans or their own to ensure they contained accurate information and reflected people’s preferences. This meant that there was a risk that people were not receiving care in the way they wanted and in a consistent manner.

There was a lack of managerial oversight at the service and the governance systems in place were not always managed effectively. Where issues were identified, there was a lack of action to address them in a timely manner and these continued.

Recruitment procedures were followed to ensure the right people for the job were employed. Staff were aware of what action to take if they thought any one had suffered any harm. Staff were aware of the procedures to follow to prevent and control infection.

Rating at last inspection: This was the first inspection since the service was registered on 9 May 2018.

Why we inspected: This was a comprehensive inspection and had been planned to start in May 2019. However, due to receiving serious concerns from people using the service and other stakeholders this inspection was brought forward.

Enforcement: Refer to the end of the full report for action we told provider to take.

Follow up: The overall rating for this service is ‘inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe and there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures which may lead to begin the process of preventing the provider from operating this service.

For more details, please see the full report which is on the CQC website at