Geocare Services Limited

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. This is the first assessment for this newly registered service. This key question has been rated 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 people’s safe care and treatment.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Effective systems were not in place to ensure lessons were consistently learnt to continually identify and embed good practice. The provider’s systems to review accidents and incidents were not always effective. Where people had falls, staff did not take immediate action and people experienced delayed medical assistance. This meant people had experience harm as a result of failures, and the provider did not have a suitable system in place to learn lessons from incidents and make changes to avoid these happening again. The provider told us there was a system in place which identified possible themes and trends for accident and incidents, however the provider was not reviewing this information or taking any action. Staff were aware when to report incidents to the manager but did not have any further knowledge of what to do in the event of an emergency. This left people at ongoing risk of harm.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. The provider failed to ensure individual care needs and associated risks were consistently assessed, monitored and planned for. People either had no care plans in place or care plans that were in place had not been kept up to date when people’s needs had changed. The manager told us one person was at high risk of falls. However, the provider had not put in a falls risk assessment or management plan which meant the person’s risk of falling had not been assessed and planned for. Information was not available to guide staff in how to manage this risk. This placed the person at increased risk of harm from falling. One person’s care records referenced them needing equipment to manage their continence. However, their care records contained no care plans to guide staff in how to manage medical devices for continence care safely and effectively. This meant we could not be assured staff were following best practice guidance when managing people’s continence needs. This meant the person was at risk of receiving unsafe and inconsistent care. People’s care plans did not contain information about a pre-assessment. However, the provider was able to tell us about the process before they started to provide support to people. Staff told us people had their needs assessed and care plans were put on to an electronic system when they began using the service. Partners told us post inspection that the provider had not met actions from an action plan implemented in early 2025.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not share concerns quickly and appropriately. The provider failed to ensure effective systems were in place to monitor and respond to safeguarding concerns. The provider’s safeguarding tracker did not match the safeguarding concerns held on our system. The provider’s tracker indicated only 2 safeguarding concerns were recorded for the year 2025. However, this did not align with the data held on our system. Our records showed there had been 7 safeguarding alerts raised between January and October 2025. These were dated 17 January 2025, 7 February 2025, 26 March 2025, 24 April 2025, 25 May 2025, 15 August 2025 and 23 September 2025. The lack of a reliable system to monitor safeguarding concerns meant the provider could not demonstrate all safeguarding issues were being appropriately escalated, tracked, and resolved. This posed a risk to the safety and wellbeing of people. Staff received training in safeguarding and demonstrated an awareness and understanding of the types of abuse people may experience. Staff told us they would report any concerns to the manager but did not demonstrate knowledge to refer concerns to external organisations.

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. Risk assessments were not sufficiently effective to ensure people’s safety.Staff supporting individuals with health needs, such as skin care needs and seizures, did not have all the information they needed in care plans and risk assessments to help support them in the event of a deterioration in people’s health. This presented a significant risk to people.We saw in 1 person’s care records, there was a reference to problems with the person’s skin and professionals were involved. Despite this, the person’s care records contained no skin risk assessment or skin care plan to enable staff to manage the risks relating to skin breakdown in a safe and consistent manner. There was also no record of communication with professionals in the care records, nor any guidance for staff to follow in the event they were unable to contact the District Nurses for advice. Another person’s care records had no care plans in place to guide staff on how to safely support them with any aspect of their care. The person’s care records stated they experienced excessive blood loss from a skin wound. No care plan was in place to guide staff on how to safely and consistently meet their skin care needs or respond to blood loss, which the manager told us was ‘normal’ for the person. This meant the person was at risk of receiving unsafe and inconsistent care. There was no moving and handling assessment to guide staff on safe transfer techniques. This meant there was a potential risk of injury to both the person and staff during support with transfers and mobility.The same person’s records also referred to them experiencing seizures. However, there was no care plan in place that described how the seizures presented and how staff should respond to keep the person safe in the event of a seizure. Additionally, the person’s one page profile referenced they used additional equipment, yet there were no care plans or guidance for staff on their use. This meant people were at risk of receiving unsafe and inconsistent care. Staff told us they were aware of people’s needs and how they would meet people’s care needs by following care plans and risk assessments. However, due to the lack of information on the care plans and risk assessments this meant people’s care needs may not have been met appropriately. One person we spoke to told us, “They vary widely in their quality and how they treat me”.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.Risk about people’s environments were not always assessed in a timely manner. One person’s care records referenced a broken hoist. Daily records indicated the issue persisted for several days without any intervention or escalation by the provider. Care records did not demonstrate how care should be delivered whilst the hoist was unavailable. This meant the provider failed to respond to risk, placing people at risk of unsafe and inconsistent care. Fire action plans for people failed to consider how people should be supported to evacuate their properties in the event of a fire. All fire plans were generic, listing doors, windows, and reporting responsibilities, but lacked personalised guidance for staff on how to safely evacuate people in the event of a fire. These findings demonstrated a failure to assess risks and implement appropriate care planning and protocols to ensure the safety and wellbeing of people. This put people at risk of harm.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Staff were not always recruited safely. There was missing information in staff recruitment files such as the reasoning for gaps in employment, evidence of relevant qualifications and references. The provider’s dependency tool showed what they were going to do and how staff would be deployed. The dependency tool stated, “The system checks the skill mix (Registered Nurses, Senior Carers, Care Assistants) to ensure each shift has the correct combination of roles.” However, the staff rota did not highlight what people’s skill mix was and where it was required. The document read as a policy rather than a tool the provider used to inform them how they were operating their staffing levels. The manager told us the electronic call logging system informed the provider whether staff were turning up to their calls on time, but it did not show what people’s assessed needs were and if appropriately skilled staff were attending to them. Staff told us they had done online and face to face training, that it was good and in enough detail for them. Staff told us they felt there were enough employees. Records showed all staff training was up to date. Some people raised carers can be late and they aren’t always informed when they are running late.

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. One person told us, “I had to ask a carer to take off their gloves and wash their hands when giving me a tablet.” The manager told us staff were not always washing their hands when transitioning from delivering personal care to providing medicines and this was an area where awareness was being raised amongst the staff team. We saw evidence of this in minutes from a staff meeting. Care plans did not contain any information about how people were protected from the risk of infection. We saw the provider's infection prevention and control policy was up to date. Staff confirmed they had access to personal protective equipment (PPE).

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. The provider failed to ensure medicines were managed safely. One person told us staff tried to give them a wrong medicine. Electronic records indicated 1 person was self-administering their medication. However, their local authority assessment plan stated the person required support with medication administration. Partners also told us the person required support with their medication. The person did not have a medicines care plan. The manager told us they would immediately start to support the person with medicines administration. This meant the provider’s assessment had not accurately assessed people’s needs relating to medicines management, leaving them at risk of not receiving their medicines in a safe and effective manner. Where people had ‘as required’ medicines, there was no guidance in place to ensure these were administered in line with how they were prescribed. This meant we could not be sure people were receiving their medicines as prescribed.