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. 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 remained 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.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate or report safety events. Effective systems were not in place to ensure lessons were consistently learnt to continually identify and embed good practice.

Feedback from partner organisations indicated their safety concerns were not always listened to or responded to effectively. For example, a partner told us they had needed to explain why an incident involving injury to a person using the service required reporting and investigation, which raised concerns about the provider's understanding of safety reporting requirements.

The local authority quality team identified concerns with the quality of records and reported few improvements for over 12 months from when they were first highlighted. While the provider recorded complaints and documented outcomes, there was limited evidence to demonstrate how learning from these had been used to inform changes or improve practice.

Although accidents and incidents were recorded and individual actions were taken, systems in place did not support effective analysis of themes and trends. As a result, opportunities to identify patterns, learn from events, and drive organisational improvement were missed. Overall, this demonstrated the provider had not embedded a learning culture to support continuous improvement and the development of good practice.

The provider did not always work well with people and health system 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.

People did not always have accurate and up to date care plans in place for all their care needs. For example, 1 person’s records identified a need for equipment to manage continence; however, there were no care plans or risk assessments in place to guide staff on how to safely manage their continence needs or associated medical devices. Staff provided inconsistent accounts of the care this person required and were unable to consistently and clearly describe appropriate actions to take if concerns arose, such as signs of infection or complications with this person’s continence needs. As a result, people were at risk of receiving inconsistent and unsafe care.

People’s care plans did not contain information about a pre-assessment. However, the provider told us about the assessment process they completed 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.

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.

The provider did not have effective systems in place to identify, monitor and respond to risks to people’s safety and wellbeing. We requested a safeguarding log or tracking system on 20 April 2026 and again during the inspection on 22 April 2026; however, this was not provided. This indicated an absence of a robust process to oversee safeguarding concerns. Although the provider shared a spreadsheet detailing safeguarding concerns identified by the local authority, this did not represent an internally maintained system for monitoring and managing safeguarding risks. The lack of oversight and effective monitoring meant safeguarding concerns may not always be identified, reviewed or acted upon in a timely manner, placing people at risk of harm. Staff had received safeguarding training and they told us they would report any concerns to the manager. However, staff did not demonstrate any knowledge around the need to refer concerns to external organisations if they felt the manager was not responding appropriately to safeguarding concerns.

The provider did not always work well with people to understand and manage risks. People gave mixed responses in relation to how their risks were managed. One person told us, “On the odd occasion, I don’t feel safe from risks”. However, another person told us “I feel risk free and safe with the carers present”.

The provider did not work effectively with people to understand and manage risks associated with their healthcare needs. Guidance to support staff in managing these risks was not consistently available within care plans or daily records.

For example, 1 person’s care records identified they had an active pressure ulcer and were at very high risk of skin deterioration. While records advised staff to follow a district nurse wound care plan, this was not available within the care records for the staff to follow. There was no clear, person-centred guidance to reflect how the person’s individual skin needs should be met or how risks to their skin integrity should be managed. Staff we spoke with were unaware of the person’s pressure ulcer and associated risks, indicating the person’s needs had not been effectively communicated or understood. There was also no evidence people or healthcare professionals had been appropriately involved in developing and reviewing care plans in order to manage these risks.

This demonstrated the provider had failed to involve people in managing risks or ensure care reflected their needs, resulting in people being exposed to the risk of unsafe and inconsistent care.

The provider also failed to ensure risks associated with other healthcare conditions were identified and safely managed. For example, 1 person’s care records referenced they had a medical condition that could result in seizures. However, there were no care plans or risk assessments in place to guide staff on how to support the person in the event of a seizure.

Staff we spoke with, who regularly supported the person, were unaware of the person’s risks relating to seizures and were unable to describe how they would recognise or respond to a seizure. This demonstrated the person’s risks had not been effectively assessed or understood, and there was no evidence the person or relevant professionals had been involved in planning their care. The absence of clear guidance and staff knowledge meant risks were not appropriately managed, placing the person at risk of harm in the event of a seizure.

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

The provider did not always ensure risks associated with the care environment and equipment use were safely managed. For example, a person’s care records we viewed identified that bed rails were required to reduce the risk of falling from bed, with the risk assessed as high. Staff confirmed bed rails were in use; however, there were no risk assessments or clear guidance in place to support their safe and appropriate use. This meant risks associated with bed rail use, including injury and entrapment, were not effectively assessed or mitigated. As a result, the person was at risk of harm due to the lack of safe systems and guidance in place.

The provider did not ensure risks associated with the use of oxygen were safely managed within people’s homes. For example, a person’s care records identified they required continuous oxygen support, with records also stating staff should ensure the oxygen equipment was functioning correctly. However, there was no guidance within the care records to support staff in how to safely manage or monitor the use of oxygen. Staff we spoke with, who regularly supported the person, were unable to describe how to provide safe support with oxygen or identify associated risks, demonstrating a lack of staff knowledge in relation to the safe use of oxygen.

Following our inspection, the provider updated the risk assessment to include oxygen use. However, although this stated staff should ensure oxygen equipment was functioning properly, it did not provide sufficient detail to guide staff in how to do this safely or how to respond to potential risks. As a result, risks associated with oxygen use, were not effectively managed, placing the person 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. They did not always work together well to provide safe care that met people’s individual needs.

Systems in place to monitor staffing and ensure people received care from appropriately skilled staff were not always effective. One person told us, “I think the carers, especially the new people need more training. I get different carers and they mean to do a good job, but they don’t always look confident”. We found instances within daily records where care calls were recorded as requiring 2 staff; however, only 1 staff member was logged as attending. This did not provide assurance that people’s assessed needs were consistently met as planned. This meant people were at risk of receiving care that did not meet their assessed needs, potentially impacting their safety and overall quality of care due to insufficient staffing and lack of appropriate skills.

The provider had a training matrix in place and records showed staff had completed mandatory training. Staff told us they received a mix of online and face-to-face training and felt it was of good quality and provided sufficient detail to support them in their roles. Staff also told us they felt there were enough staff to meet people’s needs.

However, there were gaps in role-specific training. For example, staff had not received training on the safe use of oxygen, despite supporting a person with this need. The manager told us training had been sourced following this being raised during the inspection. We will review this as part of our next inspection. Records confirmed staff were recruited safely.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.People and relatives told us staff wore Personal Protective Equipment (PPE) and staff disposed of it themselves. One relative told us, “I can’t find any faults for their standards of hygiene. They wear all the PPE”. The provider had a policy in place for Infection prevention Control (IPC). IPC audits were completed monthly. The provider’s training matrix showed staff had received IPC training and staff told us they had access to PPE. The manager told us staff had competency checks for IPC and that staff had to complete mandatory training.

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 was prescribed a time sensitive medication. However, care records did not demonstrate this was consistently administered in line with the prescriber’s instructions. This meant the person did not always receive their time sensitive medicine as prescribed, placing them at risk of harm, including deterioration in their long term health condition. However, people told us they were content with the way their medication was administered. One person told us, “I’m completely bed bound and the carers deliver my medication morning and nights in a very safe manner”. We saw appropriate ‘as required’ (PRN) protocols/guidance in place and staff completed medicines training alongside competency checks.