Domiciliary Care Experts

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• 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 legal regulation in relation to safe care and treatment and staffing.

This service scored 28 (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 effective culture of safety. Concerns had not always been fully addressed when they should have been. Robust action had not always been taken following concerns to reduce the risk of concerns re-occurring. For example, when a serious medicines error had occurred some action had been taken but the staff involved had not always undergone re-training and checks on their competency when this would have been appropriate. We raised this with the manager who then commenced undertaking staff competency checks during the inspection. These competency checks identified there were concerns with some staff practice and people had not always been cared for safely. For example, one person had been without a medicine for 3 days and action had not been taken to arrange for an emergency prescription.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Care plans did not always include important information about people such as their health needs. Staff did make referrals to other services. However, the lack of information meant there was a risk staff would not always have all the information they needed to share with other health care providers. For example, when people moved between services or to support people’s transition. When people commenced with the service their needs were assessed. However, appropriate action to ensure the service was ready to support people had not always been taken as some staff had not completed appropriate training for the role they were undertaking.

People were not always protected from the risk of abuse or neglect. Concerns were not always identified and fully addressed. For example, where people were at risk of self-neglect this had been identified and reported to the local authority. However, further action had not been taken when the concern continued. There was a lack of clear guidance for staff regarding the concern and no clear strategy to set out how staff should reduce the risk. There was an increased risk the person would come to harm from self-neglect as sufficient action had not been taken to address this.

Most staff had recently completed the care certificate which included training in safeguarding adults and children. Staff knew how to report concerns when they identified these.

Some people’s care plans did not include all the information staff needed to understand the persons health condition and how to identify concerns if people were unwell. For example, some people lived with diabetes and there was a lack of information about the signs some people might be unwell, what to do if they were unwell and how often the person was unwell.

One person’s care plan did not include any information to inform staff the person was diabetic. Whilst staff knew how to identify concerns for the people they supported, people were not always supported by the same staff, and this increased the risk new staff would not identify concerns when they arose.

One person’s care plan set out the person was at risk of choking. However, there was a lack of guidance for staff on what to do if the person choked other than to call 999. This increased the risk emergency treatment to the person could be delayed if staff did not know what other actions to take. Staff told the inspector the person had frequent chest infections. However, there was no information for staff on the risk of aspiration and staff had not considered discussing this with the person to understand if their health needs had changed and their care plan needed to be updated to reflect this.

Care plans were not always up to date nor reflected people’s current needs. One person told us, “When I first started with the service, they reviewed my care plan every 3 months, but this hasn’t happened for a while now.” The new manager and office staff were aware care plans needed to be updated and reviews of some people’s care plans were being undertaken at the time of the inspection. One person said, “[Office staff] have arranged a meeting with me and [my relative] to review [my relatives] care plan, so I am pleased about that.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. There was a lack of oversight over the safety of the equipment staff were using. Staff supported people using equipment such as hoists and stand aids. Whilst it was not the providers responsibility to service these items, they had not checked to ensure these items had been serviced regularly by those responsible. There was therefore an increased risk of staff using equipment which was not safe for use.

Not all staff had undertaken the training they needed to. Following a safeguarding concern in March 2025 the new manager identified staff lacked the training they needed to undertake their role. This included mandatory learning. Mandatory learning includes topics such as safeguarding, infection control and basic life support. Since this was identified staff had been working through the training in the form of completing the care certificate. The care certificate is a set of standards which prepares care staff for the role. However, the staff training matrix was still not up to date at the time of the inspection, and it was not clear when some staff had completed training. The manager told us 6 staff had yet to complete the training required. The training matrix was updated after the inspection. However, there was still no evidence some staff had completed training in areas such as pressure care and catheter care.

Some staff were administering medicines in a way they had not be trained to do so. Following the inspection the manager commenced a complete review of the medicine support provided by the service. During this review the manager identified staff were administering medicines in a way they had not been appropriately trained to do. Some medicines can only be administered by a medical professional or by staff specifically trained to do so by someone qualified. Staff administering this medicine had not been appropriately trained. The manager took action to address this concern. However, staff had been providing care they were not appropriately trained to provide.

Staff had completed manual handling training. However, there were no records to evidence staff had undertaken regular competency checks where their practice was observed to ensure they were following guidance safely. Medicine administration competencies were not kept up to date prior to the inspection and we identified concerns with staff practice.

Most people told us staff arrived on time, however sometimes earlier than they wanted. Comments included “I am very impressed with the carers; they always arrive on time and stay as they should.” And, “Sometimes they arrive a little earlier than I would like for my evening call.” However, some staff told us their calls were spread out across the day and this made their working day feel long. We also identified some people had care from a large number of carers and lacked continuity. We discussed these concerns with the manager who told us they were aware of this concern and seeking to address this.

Staff were recruited safely. Checks were undertaken on new staff such as seeking references from previous care employers. Staff received regular supervision.

There were sufficient levels of personal protective equipment (PPE) for staff such as gloves and aprons. Most staff had completed infection prevention control training as this was included in the care certificate.

Feedback from people and their relatives was mixed. Some people told us staff wore masks and aprons. One person said, “They wash their hands and wear masks.” Another relative told us they had to remind new staff to wear a mask because they did not always do so. Another relative told us some staff always wore a mask, but that this could make communication difficult. We discussed this with the manager who told us some staff felt more comfortable wearing masks but that they’d not considered how this might impact on communication for people.

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

Medicines administration records (MARs) were poor. There were gaps in records which were not explained, handwritten sections which were not double checked, and MARs were missing essential information. Staff did not always use the correct codes on people’s MARs. The lack of consistency meant it was not clear what medicines people had been administered. For example, some staff had used X to indicate a medicine had been administered, some to indicate it has not been administered and in some places X was used to indicate the medicine should not be administered that day.

There was a lack of information in people’s care plans about what medicines they were taking and why. This included where people’s medicines were repackaged by the pharmacy into a dosage box. Staff did not have the information they needed to identify if a medicine was missing or the wrong dose before administering it. Some medicines had been administered when there were no MARs in place to provide staff with guidance. Also there had been times when new MARs were not in place for the start of the month. There was a risk the person would not receive their medicine as prescribed as staff did not have up to date information. One person told us, “It takes a long time for the new MARs sheet to be ready in time for the next month, so sometimes, carers are working off the previous month’s MARs sheet.” Another person told us there had been times when they had been offered the wrong medicine by staff.

People were not always well supported to order their medicines to ensure there were always medicines available. One person told us, “The carers don’t tell me when I am coming to the end of my medication to re-order it in good time, because they put the empty pill packets back in the boxes, which makes them think I have more medication than I really do have.”

Where people had pain patches or creams there was not always a body map in place to inform care staff were to administer these. There was a risk staff would not know where to administer a pain patch which needed to be rotated to reduce the risk of irritating the persons skin. Where people had ‘as and when’ medicines (PRN) such as pain medicine there was a lack of information for staff about these including how many the person could take within 24 hours and what the medicine was for.

We raised our concerns with the manager during the inspection who commenced a full audit of the support people received with their medicine.