Archived: Gogomadu Cares Nottingham Office

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in people’s care, support, and outcomes.

The provider was in breach of the legal regulation relating to safe care and treatment, good governance and fit and proper persons employed.

This service scored 33 (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 make sure people’s care, and treatment was effective because they did not check and discuss people’s health, care, wellbeing, and communication needs with them.

People’s needs were assessed initially, including in relation to communication, mental health, medicines, and nutrition. However, they were not robustly monitored. Care plans and risk assessments lacked sufficient detail in relation to the support people needed, their individual preferences and strategies to keep them safe. Where there was more in-depth information it contradicted other areas of the care plan, was out of date or was factually incorrect.

There were inconsistencies in the care plan for oral hygiene care. In some places it stated the person needed prompting, elsewhere it stated staff must provide care. This appeared out of date based what the provider had told us about the person’s current restricted mobility, which evidenced it was not possible for them to complete this task. There was outdated information in the nutritional care section of the care plan which was from 2023.

There were empty sections throughout the care plan. Some examples included sight, continence, history of falls, condition of skin, pain, medicine usage, sleeping, dressing, and medical history. Clearer information was contained in the long-term care plan, but this contradicted the information in the sections at the top of the plan, which created a risk of staff or other professionals missing key information or using old information. These issues meant the person may be exposed to the risk of harm due to the out-of-date care plan, that was inaccurate and lacked sufficient detail. Improvements were implemented after our assessment.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Care plans lacked sufficient detail and did not provide clear, evidence based guidance to support people’s specific health needs or inform staff practice. Care records were not consistently completed, and where entries were made, they often lacked clarity and detail to demonstrate the care delivered. This reduced assurance that the person was receiving safe, consistent, and person-centred care.

We saw very limited evidence that the management team correctly or consistently applied national standards or evidence-based frameworks such as NICE guidance when planning and reviewing care. Best practice tools to monitor people’s wellbeing in areas such as nutrition and hydration, skin integrity and pain management were not used, including recognised clinical assessment tools, such as the Waterlow Score (a tool used to assess people's risk of developing pressure ulcers), to identify and monitor pressure ulcer risk.

Equipment prescribed to support the person’s health needs was repeatedly recorded in daily notes as not available; however, there was no evidence of follow-up action to address this or to monitor the person’s condition. When we raised this with the provider, they told us an appointment was scheduled for this to be rectified with a professional, though there was no evidence this had been identified prior to our assessment. This meant we were not assured people's changing needs were being appropriately monitored and supported.

The provider did not always work well across teams and services to support people. Staff did not always work effectively with professionals to ensure advice and guidance was communicated to staff and followed.

Where there had been complaints regarding moving and handling, there was evidence of contact with professionals to review the best way to assist the person safely with their changing needs, to keep them safe and comfortable.However, where the person had specialist healthcare needs, it was unclear who oversaw each area to ensure staff were trained and competent with equipment and tasks. We were provided with contact details by the provider for professionals who no longer worked with the person. For example, one professional’s contact details we were given as a key delegate of care advised us, they did not perform that function in the person’s care, which presented a gap or incorrect information. One professional provided feedback that most, but not all, of the support they offered to the provider was used by staff to support this person. Another professional told us they felt care tasks were not completed and told us, “They never take any advice from us.” This meant advice from professionals may not be known or followed by staff, which placed the person at risk of harm.

The provider did not support people to manage their health and wellbeing, so people could not always maximise their independence, choice, and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Systems were ineffective to ensure care plans and risk assessments accurately reflected people’s health and wellbeing needs. This meant staff did not always have the information required to support people safely and included clear guidance on emotional support needs or details of the professionals involved in each aspect of the person’s care. This was particularly significant where specialist healthcare tasks were required. There was limited direction on what action staff should take if those professionals were unavailable, which increased the risk that essential specialist oversight was missed.

There was limited evidence that people had been meaningfully involved in reviews of their health and wellbeing needs, and care plans were not consistently kept up to date. This meant the provider could not reliably assess, monitor, or respond to changes in people’s health, which increased the risk of declining wellbeing, unmet health needs, and avoidable deterioration.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Care plans had not been robustly reviewed routinely or following incidents, to show improved outcomes and quality of life for people. Some staff meetings had taken place which included discussions about people’s health and wellbeing. There was limited evidence this had led to an update or review of care planning to improve people’s outcomes.

The person’s weight was not being routinely recorded. For example, this was last recorded in March 2025, and there was no height recorded. Failure to record weight limits early identification of health deterioration and increases the risk of harm due to delayed intervention or inappropriate care.

Although the person told us staff supported them well, feedback from others indicated concerns in this area. Without systematic and reliable monitoring, the provider could not be assured improvements were consistent or that the person’s outcomes that met both clinical expectations and their own preferences.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment. Staff were aware of their responsibility to obtain consent, including people’s right to refuse care, and there were no people supported who lacked capacity at the time of the assessment.

However, it was not always clear that people were fully informed of the risks associated with refusing certain elements of care or the use of equipment. Care records indicated that staff supported people with tasks related to nutrition and hydration which were recorded as the person’s wishes but went against best practice guidance and recommendations, without clear evidence that risks had been discussed or reviewed. This created a risk that consent was not always fully informed and that people could be exposed to avoidable harm.