Allfor Care Croydon

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 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 regulations in relation to people’s safe care and treatment, safeguarding users from abuse and improper treatment and duty of candour, staffing, fit and proper persons employed, notification of other incidents and good governance.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their representatives reported missed and frequent late call visits as a major concern. Comments included, “They (care workers) can be late far too often. I never know when they're going to be late, they just turn up with no notice or apology”, “The timing is not too bad but not great either. The teatime call is always late without fail” and “(Family member) needs two carers and they (care workers) never arrive together. One carer turns up and just sits on the wall waiting for the other to arrive and she won’t come in.”

The service faced significant governance failures driven by a history of missed and late calls, resulting in a local authority suspending it from taking on new care packages from 19 April 2023 to 8 January 2024. The provider failed to notify the Care Quality Commission (CQC) of this suspension, which is a legal requirement. A lack of a learning culture was evident, as management failed to specifically audit missed and no-show calls in their electronic monitoring system (EMS), despite completing an 'SG tracker complaints and incidents 2025' audit which only tracked occurrences of cancelled or short-call visits from January to June 2025. There was no evidence of analysis or learning to take away and share to prevent similar occurrences in the future.

The service’s Quality Monitoring tools consistently identified issues without providing adequate follow up. For example, a quality audit tool dated 4 April 2025 noted recurring problems, such as care worker lateness and poor communication, but offered no detailed action plan to ensure effectiveness. Another audit tool dated 21 April 2025 reported several medicine errors since December 2024. Examples included a person who missed medicine 6 times in December 2024 and another person with 7 unexplained missed administrations between January and April 2025. The lack of a complete record of all errors and learning to prevent recurrence, limited the effectiveness of the monitoring and learning process.

Recommendations to improve care record accessibility were not fully implemented. A local authority report dated 3 January 2024 advised paper-based initial assessments and Medication Administration Records (MARs) be scanned and stored electronically. However, during our visit on 25 June 2025, this was found to be incomplete. Although the registered manager stated lessons learned from incidents were shared in management and staff meetings, with minutes from 7 January 2025 to 24 June 2025 supporting this, there was no records to show agreed actions and the changes made to staff work practices going forward.

People and those who represented them shared their experiences of joining the service. Comments included, “Actually, it was quite quick, within 48 hours of discharge”, “It’s been 5 months since they (care workers) started coming and there’s still a few niggling details that haven’t been ironed out properly. The main one is that there timing is hopeless, often I don’t know if they’re going to turn up at all. The office says that they’re sorting it out, but they never seem to manage it”, “I have not seen a care plan in place. They (care workers) do not know what to do when they arrive” and “The carers don’t seem to have been briefed on anything. They are just guessing what needs to be done.”

The service's pathways and transitions systems placed people, many referred via the Discharge to Access (D2A) programme, at risk of harm. A critical failure was the consistent use of local authority D2A assessments as initial care plans. These lacked the detailed information necessary to enable staff to provide safe care. We were informed a comprehensive assessment should be completed within 72 hours of a package starting. However, this deadline was frequently missed, with people and staff reporting a lack of information on the day of first care call.

The failure to follow agreed safety protocols was a systemic problem. In one example, care was delivered to a person without staff assessing their care and support needs. In one example, care was delivered to a person without staff assessing their care and support needs. The person’s care records showed that the initial assessment was completed 10 days after the care package had commenced. This meant the service’s requirement to complete assessments within 72 hours was not met.Another example showed a person with dementia whose care started on 9 September 2024, but the first assessment was not scheduled until 4 October 2024. Additionally, the service's 'Initial Assessment Policy', dated 15 April 2025, lacked documented procedures for allocation officers and supervisors, increasing the potential for inconsistent and unsafe care.

People gave mixed feedback regarding feelings of being safe from abuse, with responses based on relationships with care workers and the timeliness of care visits. While some people felt safe with staff due to the regularity of calls and caring attitudes of care staff, most people told us they felt unsafe because of visits from staff they were not familiar with, rushed care call visits and late, no-show, or missed calls.

Comments included, “On Tuesday it was my carer's day off and a complete stranger just turned up and let themselves in. She happened to be very nice, but it was still a nasty shock” and “Mum is definitely worried about her care. It was all done in such a rush, there was no time to explain anything. She doesn't feel confident being left with people she doesn't know. She worries that something could go wrong, and no one would notice.”

The service failed to protect people, as persistent late and missed calls combined with monitoring systems which were not fit for purpose placed people at significant risk of harm. An instance of potential neglect was reported by a relative after a completely missed call left their family member without medicine, breakfast, or water. Management failed to recognise this as neglect and did not follow their Safeguarding policy dated 20 October 2024 by promptly reporting it to the local authority. The policy itself was inadequate, failing to incorporate the mandatory three-step criteria from the London Multi-Agency Adult Safeguarding Policy and Procedure (April 2019), hindering a proper response to potential abuse.

The provider also failed to meet its statutory obligations for reporting incidents. Between January and May 2025, the safeguarding tracker showed 12 incidents, but only 9 statutory notifications had been sent to the CQC, demonstrating a lack of compliance with regulatory duties. While staff received relevant safeguarding training, the provider's system for assessing competency was ineffective: they used an 'All for Care Croydon (AFC) Safeguarding Competency Test' but kept no documentation on how often competency was checked nor individual staff responses, making it impossible to identify and address knowledge gaps.

The provider failed to do all that was reasonably practicable to mitigate risks to people's health and safety, placing people at risk of avoidable harm. Risk assessments and management plans were consistently ineffective. Where people were identified as being at risk of falls and needing support with moving and handling, there were no corresponding risk management plans to mitigate these specific hazards during mobilisation. This left people vulnerable to injury while receiving care and support.

Supervisors also failed to adequately identify and manage health risks for people with multiple medical conditions, such as asthma, epilepsy, and dementia, during initial assessments. Consequently, the resulting care plans lacked the necessary risk assessments and control measures required to reduce risks to a reasonably low level. This widespread oversight placed people at risk of avoidable harm because their complex health needs were not properly planned for.

Internal auditing processes were ineffective in ensuring risks were mitigated. A care plan audit, completed on 7 May 2025 and uploaded on 3 July 2025, reviewed peoples’ care plans and identified unaddressed risks, including one person at risk from improper catheter care and another from pressure ulcers. However, the audit's "actions" section failed to specify the required work or a completion date. This meant the identified risks, though known to the service, were not assuredly mitigated.

The provider's 'Assessing and Managing Risk for People Who Use a Care Service' policy, dated 20 December 2024, outlined the importance of risk management but failed to provide staff with practical guidance on how to accurately assess risks and develop appropriate management plans. Furthermore, despite supervisory staff having attended role-specific risk management training, the continued issues demonstrated the training had not been properly embedded into practice.

Staff had access to information on how to identify and manage risks to people’s health and welfare, as well as risks to staff. The service had a Health and Safety Policy in place. The provider's staff handbook included safe working guidance and relevant health and safety information outlining the work practices staff were expected to follow.

However, areview of the service's Quality Audit Tool, dated 21 April 2025 completed by the registered manager, showed health and safety matters were not consistently followed up.

For instance, the audit included a question about whether people with specialist equipment (such as mobility aids) had been appropriately maintained, and risk assessed. The only documented response was a general action point which stated, ‘Manual handling risk assessments need to be more person-centered.’ This did not answer the question and furthermore, the action item was ineffective because it failed to specify which people were affected by this issue or when the identified action was due to be completed.

Environmental risk assessments and various checks were undertaken by supervisors to identify potential risks. Staff had received health and safety training.

People gave mixed feedback about care worker’s competency to provide care and support to them.

“Weekend carers don’t seem confident or well trained. (Family member) needs clear instructions, but they (care workers) don’t explain things well to her or understand what she is asking.” Training is on the job, and they (care workers) don’t have the time or knowledge to adapt when something goes wrong.” They (care workers) do not know what to do when they arrive. The carers don’t seem to have been briefed on anything. They are just guessing what needs to be done.” Whilst other feedback included, “She (care worker) seems to know what she’s doing and I’m happy with how she supports me.” They (care workers) are very good girls. I think that one of them is training to be a nurse” and “The carers I have are very knowledgeable about what I need”.

The service failed to ensure staff were adequately trained, supervised, and appraised. Training records were unreliable; for example, a care worker's competency assessment on 10 January 2025 and appraisal on 27 March 2025 both noted a need for specialist PEG training, yet the training matrix incorrectly showed completion on 8 August 2024. This suggested people with specific needs may not have received safe care. Supervision was inconsistent: the policy dated 7 September 2024 required 6 sessions annually, but 22 care workers had not had one in 6 months, and records often lacked detail or necessary signatures. Furthermore, supervisors failed to ensure staff competency improvements were followed up. For example, a manual handling issue was identified on 26 February 2025 but had not been followed up at the time of this inspection.

Supervisors failed to effectively manage staff performance regarding service delivery. Despite the registered manager's assurance staff were being monitored for late and missed calls, a review of staff members' records showed that while late arrivals were noted, there were no documented in-depth discussions or planned actions to prevent recurrence.

Recruitment practices were not line with the regulation. The service failed to ensure staff suitability; for instance, 6 staff records had unexplained employment gaps. Although gaps in employment were reviewed and addressed, the process was not applied consistently. Pre-interview analysis was frequently incomplete, indicating a lack of rigor that prevented the provider from confirming staff were of good character and suitable for their roles.

Most people and their relatives said the service protected them from infection. They reported staff wore personal protective equipment (PPE) and washed their hands before providing care. Comments included, “They do wear PPE. Maybe not a mask but they do wear gloves, aprons and shoe covers. I have supplied slippers for them if they forget their shoe covers”, “I have provided everything, gloves, aprons, masks and shoe covers. It is only this last week that he brought everything himself. I had no idea that they supplied their own PPE” and “They bring their own masks, aprons and gloves and I provide shoe coverings.”

The service's infection control practices were not effectively monitored to ensure people were protected from infection. While most feedback was positive some people did share their experience of poor infection control practices. For example, a person told us a care worker did not change their gloves in between care tasks. Competency records did not record if assessors had observed poor infection practices and what action was taken when this happened. For example, a review of the service’s ‘Infection Control’ audit dated 2 July 2025, showed 20 records were reviewed, but it did not specify which records were reviewed or what the findings were. Some audit questions were left blank, while others had irrelevant answers. This showed the service's infection control audit was not effective at monitoring and identifying poor infection control practices.

The service’s training matrices showed all staff had received infection control training. They had access to the service's Infection Control policy (dated 5 May 2025) and the 'Staff Handbook 2024 to 2025', which provided guidance on techniques like proper handwashing, handling of blood/bodily fluids, safe clinical waste disposal, and prompt illness reporting to ensure compliance with relevant legislation.

Some people and relatives spoke positively about medicine support and said they were administered safely. However, others felt missed and late call visits had a negative impact on their medicine regimes, placing them at risk of harm.

Medicine administration practices were not always safe because staff did not follow the provider's medicine policy and current best practice. The provider’s Medicine Administration policy dated 28 August 2024, and the guide in the staff handbook lacked crucial detail required by current legislation. Specifically, they failed to clearly instruct staff to ensure MARs include essential information like the person's name, date of birth, NHS number, medicine details, administration times, or known drug allergies. Furthermore, there were no key codes to explain refused or missed doses, and these details were not consistently recorded across the 5 MARs reviewed.

A review of electronic MARs showed people did not consistently receive their prescribed medicines, a failure that poses a serious risk, particularly for those with dementia. One person did not receive their medication 5 times in April 2025. Another person did not receive their medication 19 times in June 2025, with no explanation recorded. Inconsistent or missed medication can have a serious and detrimental impact on the well-being and symptom progression for people living with dementia.

Safety information for high-risk medications was not available for staff. MARs for people prescribed anticoagulants (blood thinners) lacked crucial safety information. Furthermore, 'medication risk assessments' did not properly identify the risks associated with these medicines or outline control measures to minimise harm, placing people at potential risk of serious injury.

Protocols for PRN (as and when required) medicines were not consistently detailed in people's care records or daily notes, meaning people could not be assured PRN medicines would always be administered safely and documented when given. Although staff competency to administer medicines was assessed and medicine audits were completed, these internal processes failed to identify any of the serious concerns found during the assessment, highlighting the inadequacy of the service's oversight mechanisms.