During an assessment under our new approach
Date of Assessment: 23 July to 4 August 2025. The service is a care at home service registered to provide care to older people, adults with physical disabilities, and adults who have a learning disability or autism. This is a small sized service, the registered manager and provider are the same person.
We found 4 breaches of the legal regulations at this assessment in relation to the ineffective quality monitoring of the care provided. People were not always kept safe. Staff were not safely recruited. Staff were also not effectively trained and supported to perform well in their role. No one had come to harm as a result of these issues, but there was a potential risk some people might in the future unless improvements are made. There were two continued breaches in relation to keeping people safe and the governance of the service, from the last inspection in 2021.
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There was a lack of effective provider and registered manager oversight at this service. There were no systems in place to enable the functioning of the registered office in the absence of the provider and registered manager. The provider and registered manager did not audit the quality of the care provided to assure themselves the service provided safe and appropriate care to people. There was a closed culture at the provider level. At times they were not transparent with us.
Staff were not safely recruited to ensure they were suitable to support people at the service. The provider did not have the recommended processes in place to check staff who came from overseas could legally work here. There was insufficient staff and plans in place to safely meet people’s needs if the provider’s one member of staff was absent.
The provider had not provided up to date training in key areas required. The provider was not assessing this member of staff’s competency; to check they were providing safe and effective care to people. Staff did not have regular supervision and team meetings.
The provider had not ensured people had thorough risk assessments and care plans to support staff to meet people’s needs safely and direct them if something went wrong. There was no emergency plan in place to enable the provider and staff to respond to an emergency at the service.
It was not made clear to people they had consented to the care plan the provider had created. Nor was it made clear to people when the provider may need to share their sensitive information with other professionals.
An assessment has been undertaken of a specialist service that is registered for use by autistic people or people with a learning disability. At the time of the assessment, the service was not used by anyone with a learning disability or an autistic person. However, the provider had not made sufficient plans to ensure they were ready and prepared to provide care to people with a learning disability or autistic people when this happened.
The provider said they would take actions to make improvements. The provider contacted us during the assessment about some of the actions they had taken and planned to take following our assessment and feedback.