Domiciliary Care Experts

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question Good. At this assessment the rating changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some staff told us there had been concerns about the culture which had developed at the service, and this had raised concerns about the provider’s oversight of the service at the time the culture developed. However, some of these staff also told us the culture at the service was now improving under the new manager. The manager had begun to make some changes within the office and changes to some processes. One staff told us, “I think it is improving, [the manager] sends a lot of memos on what we are doing good and what we need to improve on.” Other staff told us they were now happier in their role. However, there was still improvements to make, and other staff told us they had not yet felt the impact of improvements.

The provider had not always had good oversight of the service and relied on the manager to raise concerns with them. The provider, who was also the nominated individual, met with the manager once a week to discuss concerns. However, they did not undertake any overall audits or quality assurance checks. Prior to the new manager, concerns had arisen which had not been identified and addressed appropriately in a timely manner. The new manager identified concerns which should have been identified prior. For example, the manager identified staff mandatory training was not up to date. In March 2025 they wrote to us and told us, ‘I identified that the care staff needed to complete the care certificate and majority of the mandatory training.’ Since the manager commenced in post, they also identified some staff were undertaking tasks such as the use of restraint and invasive medicine administration when they were not appropriately trained to do so. These practices left people at risk of harm and should not have occurred.

Concerns were not always reported to CQC when they should have been. Concerns had been raised by a staff member regarding one person’s continence support. The concern was reported to the local authority as an accusation of abuse, but a notification was not sent to CQC and it needed to be as this is a legal requirement. Other notifications had been submitted as appropriate.

People and their relatives told us communication with the office needed to improve. Comments included, “They don’t always get back to you quickly, you might have to wait a few days.” A number of people expressed this was a source of frustration and there were delays in communication.

Feedback from staff was mixed. Some staff felt listened to and found office staff to be responsive. Other staff expressed frustration and told the inspector they found communication with the office difficult and would prefer to be able to speak to office staff on the phone more.

There was also still some mixed feedback from staff about how valued they felt. How travel time and milage was managed was a common concern for some staff. The manager was aware some staff were not happy and was taking steps to discuss staff concerns. They had not been successful at getting staff to attend face to face meetings, so was setting up a team meeting to see if this improved staff attendance. The manager told us, “I am trying to make staff feel comfortable and open up the relationship.” However, the managers time was limited due to the business of the role, and this restricted how accessible they were able to be to staff. There had also not yet been a staff survey to provide an alternative route for staff to raise issues about how the service was run.

There was mixed feedback from staff regarding how staff rotas had been structured. Some staff raised concerns about the layout of their day in that they had long gaps between some calls so ended up working long days which impacted on their personal life. Other staff worked shifts and felt more positive. They told us they were able to be flexible with their shifts when they needed to spend time with their family. The manager told us this was being reviewed to make improvements for staff.

Staff had completed training in equality and diversity to ensure they had an understanding on how this impacted on them and the people they supported. However, communication continued to need to be improved between staff and management to ensure there was an effective route for staff to raise concerns and receive support.

The provider did not have clear effective systems of accountability and good governance which led to quality standards being improved where concerns were known. Governance systems need to be reviewed and improved. There was a lack of oversight at the service and systems and processes had not been used effectively to ensure people were provided with safe and effective care. For example, the new manager told the inspector prior to the inspection only 10% of medicine administration charts were audited. When there are no concerns, this is often sufficient. However, concerns about medicines had been identified and had been discussed at staff meetings as far back as October 2024. Concerns about the standards of medicine recording was a common theme at staff meetings. However, we identified there were still significant concerns during the inspection in June 2025 as quality assurance systems had not driven forward improvement.

Systems had not ensured staff had kept up to date with training and competency assessments.

Quality assurance systems had failed in other areas such as ensuring some peoples care plans were up to date and accurate, so staff had the information they needed to support people safely. For example, one person’s care plan stated they no longer used a medical aid, staff confirmed the person still used this. The plan also stated the person had an emergency medicine they no longer took and did not mention the person’s diabetes status despite the person taking diabetic medication.

Some management reports produced by the IT system contained conflicting information and did not provide clear oversight of what was occurring. This was because care visits needed to be confirmed manually and there was an over reliance on service user’s complaints to identify if calls were shorter than planned or late.

Staff worked alongside health and social care professionals to provide support to people. However, information about people’s health care was not always then included in their care plans and medicines administration records were not always current. Some guidance for staff from professionals was available in people’s care plans. For example, on how to support people who used hoists. However, information shared by other professionals such as high blood sugar had not always been used to update care plans. Staff had contacted health care professionals such as the district nurse and doctor when they had identified people needed this support. However, not all feedback from partners was positive and some concerns were raised about the services performance which aligned with the concerns we identified during the inspection.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Prior to the inspection we received an action plan in April 2025 from the provider setting out how the new manager would rectify concerns they had identified. This included making improvements to areas such as risk assessments to people and medication audits. The action plan was not focused on the biggest risks and the timescales were not achievable and therefore not met. There had not been sufficient consideration of the level of the management time and admin resources needed to make the improvements required.

During the assessment the provider wrote to us and told us they planned to roll out an electronic care plan system as part of how they planned to improve the service. However, the manager and office staff were already extremely busy, and they did not set out how they planned to effectively resource this roll out when care plans and other documentation needed to be updated as well. We raised this with the provider who told us they planned to make some changes to staff resources.