Domiciliary Care Experts

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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in continued breach of legal regulation in relation to people’s safe care and treatment and staffing. The service was in breach of legal regulation in relation to fit and proper persons employed, staffing and the ways people’s medicines were managed safely.

This service scored 34 (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 positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not always learnt to continually identify and embed good practice. Robust action had not always been taken by the provider and manager following concerns to reduce the risk of concerns re-occurring, accident and incident records had not always been reviewed and acted on. For example, we viewed an incident form which showed that a person was displaying some behaviour such as spitting which put staff at risk of infection. The incident had been reviewed, and it identified that staff needed to be given additional personal protective equipment (PPE). The person’s risk assessment had not been updated to reflect this and staff confirmed they were not provided visors to protect themselves from a healthcare related infection.

The provider and manager had not reviewed the completed accidents and incidents forms which had taken place in October, November and December 2025 to ascertain if actions were required, to check if there were trends and themes identified. Whilst there had not been significant numbers of accidents and incidents reported (approximately 5) this still had the potential to put staff and service users at risk of potential harm.

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. No new packages of care had been taken on since we last assessed the service in 2025. When people commenced with the service their needs were assessed, however when their needs changed, they were not always re assessed in a timely manner.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Some people told us they did not feel safe from abuse and neglect. A person told us about a safeguarding situation involving a staff member which happened to them, and how this had left them feeling vulnerable and scared. They shared they had not been supported appropriately and let down by the provider for failing to safeguard them effectively. They felt they had been subject to ‘victim blaming.’ The provider was aware of the incident, and the staff member was no longer working at the service. A relative said, “Do I feel that my relative is safe, No.”

The provider and manager had made safeguarding referrals to the local authority. Safeguarding and whistleblowing policies were in place and were accessible to staff. Staff were aware of the whistle blowing policy. Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff were similarly aware of whistleblowing, and most were confident to speak up if needed. Staff said, “I would report abuse to my care coordinator. It would be dealt with. I could report it to CQC” and “I would document abuse and report it to the office as well as the care manager. It would be dealt with.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people were not always identified and risk assessments lacked enough detailed information for staff to know how to keep people safe. For example, a person was insulin dependent diabetic, they lived with Parkinson’s disease and had a blood disorder. Their risk assessments did not detail safe ways of working with them, such as providing information to staff as to what action they should take if they were bleeding. A member of staff had suffered a needlestick injury whilst working with a person. The risk assessments did not provide staff information on dealing with used needles and what action they should take to keep themselves safe.

Risks in relation to people taking blood thinning medicines had not always been assessed. A person’s care records showed they were prescribed a blood thinning medicine, in August 2024.There was no risk assessment in place to provide staff information about how to provide safe care if the person cut themselves or fell or developed bruising.

A person’s care records evidenced they were prescribed some medicine due to stress and distress in Alzheimer’s Disease or delirium. There was no risk assessment for stress, distress or delirium to enable staff to work with the person safely. Another person’s care records showed they had tried to take their own life several times. The risk assessment lacked guidance on how staff should work with the person.

Catheter care risks were not always well managed. A person’s risks relating to catheter care had not been assessed. Another person’s care records provided some basic information, but staff were not provided with all the information they needed to support the person safely. For example, risks of infection, catheter blockage, catheter bypassing were not assessed, and they were not provided with clear guidance to mitigate these risks. This put people at risk of harm. Some care records evidenced that people required their fluid input recorded to make sure they were drinking enough to stay healthy. However, there were no records to evidence this was taking place and no evidence that the provider and manager were monitoring this.

We received mixed views from people and relatives about their safety. A person said, “I am having problems with the carers leaving my back door open, I live by myself in a bungalow and I only know this is happening when a friend or relative comes around to check on me. We do contact the office every time this happens, but it shouldn’t be happening and I am very worried and concerned for my safety.” We reported this to the manager, and they took action to address this with staff. Another person told us, “I feel safe with the carers. They hoist me and there are always 2 of them and they always wait for one another before they start.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

There continued to be 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. The equipment list showed 12 people used hoists and slings which had not been checked in relation to meeting Lifting Operations and Lifting Equipment Regulations (LOLER) regulations to maintain and check lifting equipment. This put people and staff at risk of serious harm. After the assessment the provider presented copies of correspondence dated July 2025 to show they had tried to gain evidence of checks.

The provider did not make sure staff were recruited and deployed safely. Staff had not always received effective training and development to meet people’s assessed needs.

Staff reported that they did not always get adequate time to travel between care visits. The provider’s records from their electronic call monitoring data also verified this. Some people and relatives told us, “I have complained to the office saying that they just do not get enough travel time. The office just apologises and say they will look into it but that is as far as it goes. I have had meetings with them via social services about it, but it does not change”, “I do sometimes get a call to say they may be late, but they have never missed a visit”, “They are sometimes late but they don’t always let me know, the office just do not bother to tell me what is going on” and “If the carer is not here for 0740, I give them until 0800 and phone the office who then phone the carer to check where they are and how long they will be. It doesn’t happen very often that they are late, maybe 3 to 4 times.”

We found that staff were not always deployed in a safe manner as they had not been given adequate breaks between shifts, which put them and people at risk. We received feedback from a relative during the assessment that staff had not had an adequate break between a night shift and day shift. The provider’s staffing rota verified this. The rota showed this staff member had worked 2 shifts in a 24 hour shift with only a 4 hour break. This is not compliant with The Working Time Regulations which mandate an 11 hour continuous rest period per day. This issue had been reported by relatives on more than one occasion. Rotas, electronic call monitoring for November 2025 also showed this was frequent practice. Staff members confirmed this.

Staff had not always been safely recruited. All required recruitment checks had been carried out, and documents were all in date. However, not all staff files contained a full employment history and reason for gaps. Interview records did not evidence that this had been discussed and explored with staff. A staff file contained inconsistent information in regard to references obtained. For example, a reference was provided for employment which was not listed on their application form. The provider had retained copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. The provider had not always followed UK employment law in relation to workplace pensions. Four staff told us although they had opted in to the pension scheme no deductions or payments to a pension had been made. A staff member also reported concerns in relation to tax deductions. We reported these concerns to HM Revenue and Customs. The provider told us they used HMRC approved software to run the payroll and that they had no control over deductions, these were automatically processed by the system.

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. For example, staff were supporting a person with specialist healthcare needs, however not all of them had received the appropriate training to meet this person’s needs. A child who was supported by the service used Makaton sign language to communicate. There was no record of Makaton training on the training matrix, staff had not completed this. The provider’s training records evidenced that staff had not attended Oliver McGowan training for learning disability and autism. The Oliver McGowan Mandatory Training on Learning Disability and Autism is the Government's preferred and recommended training for health and social care staff. Some staff fed back that although they had completed moving and handling training they had not practiced using moving and handling equipment as part of their training. After the assessment process had ended the provider told us that Makaton training was in the process of being arranged and since the assessment all staff had completed Oliver McGowan training.

Some people and relatives told us staff had the skills and experience to provide safe care. Some told us they felt staff did not. Comments included, “I also do not feel they are trained well either”; “They are trained well”, “It does annoy me when 2 of them arrive together and neither of them know what to do” and “I really think that the carers need more training as most of them do not know how to react with my relative and it is sad to see my relative getting upset because they want to be the one interacting with the carers not me.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Staff were provided with PPE to protect themselves and people they were supporting. There were stocks of PPE at the office, and we saw staff were freely able to collect this when they were running low and were passing. However, staff had not always been provided with appropriate PPE to meet additional infection control needs, we detailed this within the learning culture section of this report.

Staff told us they wore PPE to keep themselves and people safe from risks of infection. Comments included, “We do have PPE; aprons, gloves, sanitiser and shoe covers on request. We received an email 2 or 3 months ago asking us not to wear masks as some clients were complaining they could not hear properly. We were told they would not be supplying masks anymore. I do wear a mask if I have a cold” and “We have masks, aprons and gloves. We have been told elsewhere that we can use masks only for clients with breathing problems. I do wear one if I have a cold.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines care plans were inconsistent. Some care plans were really detailed and showed what medicines people were taking and why. Other care plans did not provide this information.

A person’s care records evidenced they were prescribed a medicine for stress and distress in Alzheimer’s Disease or delirium. The medicine was usually administered by their relative when it was required. However, the care records showed that staff were responsible for medicines within the daily schedule. There was no more information on this to enable staff to provide medicines support in a safe way. There was no medicines administration record chart (MAR) to detail what dose the staff should give.

Another person’s care stated their relative managed all their medicines. However, it also stated if the relative was not home staff would need to administer medicines. There was no individual MAR for this person. The provider told us, if the relative was not available to give the medicine, it would be added to the electronic MAR and staff would administer the dose. The electronic medicines record showed that staff were only informed about a prescribed cream and not the tablets they were prescribed. This meant staff would be unaware of the time for medicines to be administered and the route of administration. Another person’s care file contained a photograph of a hospital discharge report which listed medicines the person had been discharged from hospital with. None of these medicines were listed on a MAR or the care plan, even though staff were supposed to be prompting the person to take their medicines daily. There was a risk that staff would not know which medicines to administer to the person.

A person’s care file provided conflicting and confusing information for staff as to the person’s support needs. At some points, the care record showed staff were prompting the person to take their medicines only and in other parts it described actions that staff should take which showed they should be administering medicines. A staff member said, “Sometimes I’m not 100% sure what medicines are for, I google it. Most people are prompted with their medicines.”

Despite the evidence above, people and relatives told us, “They do give me my medicines and that is recorded on the app on their phones” and “They give [person] their medicines and that is all recorded on the app. They are given at the correct times.”