Diamond Gate Care Services Limited

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• 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 inspection for this service. The rating for this key question is requires improvement. This meant some aspects of the service were not always safe and we were not fully assured about safety.

We found the provider to be in breach of 2 legal regulations relating to safe care and treatment, and fit and proper persons.

This service scored 50 (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 robust system in place to ensure all accidents and incidents were logged, followed up and learning was effectively identified and disseminated to all staff to embed best practice and reduce reoccurrence of incidents. For example, a risk assessment for 1 person in relation to verbal and physical aggression, recorded that incident or accident reports must be completed following each episode of behaviours of concern. There were 2 incidents in February 2025. The first incident/accident occurred in the kitchen of the person’s home, which resulted in a broken drawer and a minor injury. The other incident involved the same person locking their bedroom door and not allowing staff in. However, we saw that these accident and incidents were not recorded in an accident and incident log, nor were there any follow up actions documented. These accident and incidents were also not identified in the audit carried out in February 2025. This meant themes and trends in relation to accidents and incidents could not be established to drive improvements and share learning with staff.

Incidents were logged on ABC charts (ABC chart is an observational tool that allows staff to record information about a particular behaviour. The aim of using an ABC chart is to better understand what the behaviour is communicating). However, we found that ABC charts were not always analysed to identify, themes, trends or factors that could trigger or reinforce acute behavioural incidents. Therefore, learning and best practice could not be shared with staff.

The provider did not have a robust system in place to ensure learning was effectively identified and disseminated to all staff to embed best practice and reduce reoccurrence of incidents.

Systems were in place to ensure continuity of care. Assessments of people’s needs were carried out prior to joining the service to ensure their care needs could be met. Care plans showed the involvement of health care professionalssuch as social workers.

There were safeguarding, whistleblowing and duty of candour policies in place. However, the safeguarding policy did not include details of local safeguarding teams or CQC, to whom safeguarding concerns should be reported to.

Staff had completed safeguard training. There had not been any safeguarding concern, however,

Staff could not describe the different types of abuse and reporting procedures if they had any concerns.

Risks to people were not always identified and managed to ensure people were kept safe. Risk assessments and management plans did not always include information about how to minimise associated risks and maintain people’s safety in accordance with people’s specific needs. For example, there were not always person-centred risk assessments or risk management plans in place for sharp objects, locking bedroom doors and if medicines were refused. One person’s health and safety risk assessment did not document what staff should do, should the person have an accident.

The risk assessment in relation to behaviour of concern for this person documented a referral was made to mental health teams in January 2025, but to date, there had been no follow up. We brought this to the attention of the registered manager, who confirmed that they would follow this up. In relation to this risk assessment, the management plan records stated that the person required clear boundaries. However, these boundaries were not clearly documented for staff to follow and staff we spoke with were not able to fully describe boundaries that were in place, except to keep calm and give the person space. This meant that staff were not always aware of how to safely support the person.

This person’s risk management strategy stated that ‘A positive behaviour support plan (PBS) will be developed in conjunction with psychologist’. However, the registered manager confirmed that they were yet to put the PBS plan in place. This was confirmed when we spoke with staff as they were not aware of a formal PBS plan.

Following the visit to the service, the registered manager sent us an updated sharp objects risk assessment which stated, ‘All staff are trained to respond calmly and effectively if an incident occurs’ and ‘Support person in managing emotions to prevent impulsive or distressed behaviour.’ However, it did not detail how staff should respond ‘effectively’ and how they should support the person to manage their emotions.

Although staff supported the person with their nutrition needs, there were no risk assessment and management plans in place for nutrition, This meant that there was a risk that staff may not be able to safely support the person in relation to nutrition.

Environmental risk assessments had been carried out for people’s homes and included cluttered environment, unsafe kitchen appliances, electrical equipment and bathroom safety. However, it was not clear which electrical items this included, except phone chargers. There was no information about what was covered in bathroom safety. We also saw that fire safety risks had not been assessed and mitigated in relation to the home environment.

We saw that electric items had been tested and deemed safe. Regular carbon monoxide detector and fire alarm tests were carried out. People had personal evacuation plans (PEEPs) in place which detailed the support they required to evacuate in the event of a fire.

Recruitment processes were not robust and were not consistently implemented. People were at risk of receiving care from staff that had not been proven to be of good character before they were employed. We reviewed 3 staff files and saw Disclosure and Barring Service (DBS) checks were not carried out for all staff before they were employed. DBS checks ensure staff do not have any criminal convictions and were suitable to provide support for people.

We also saw DBS checks carried out by previous employers were accepted by the provider for 3 staff members. For example, one staff member started work in July 2024, a DBS check dated September 2023 from a previous employer was accepted. The provider did not complete their own DBS check until May 2025. A second staff member started work in March 2025, but a DBS check was not completed until May 2025. A third staff member started work in March 2025, but a DBS check dated January 2025 had been accepted from a previous employer. Following the inspection the provider sent us a DBS check for this staff member that they had carried out after the onsite inspection in May 2025.

Providers must be able to demonstrate sound reasons for not obtaining a full DBS check before a staff member was employed and also demonstrate any potential risk had been assessed. For all 3 staff members, there were no reasons recorded as to why a full DBS check was not obtained by the provider and potential risks were not assessed.

The staff files we reviewed showed that the provider had failed to ensure that two adequate references (one of which must be from the most recent employer) were obtained before staff commenced work.

We found for 1 staff member; their references were not received until a month after they started work. We also saw that an application form for 1 staff member did not record their education or qualifications history. There was also a 2-year gap in their employment history which had not been accounted for.

Staff file audits completed; were not robust as they failed to identify the issues in relation to DBS checks, references and application forms we found at this inspection.

The provider did not have an electronic call monitoring system that accurately reflected the times staff attended care calls. The provider told us this was because currently there wasn’t a need for this system as they only had 1 person using the service and they were able to effectively monitor that staff were punctual in attending care calls by telephone. If staff were going to be late, they informed the office, who would let people know. The provider told us that there had not been any late calls and staff confirmed this.

Staff told us there were sufficient staffing numbers to safely meet people’s needs.

We were not able to speak to people or their relatives about infection control.

We saw the provider had infection control policies and procedures in place and staff received training in infection prevention and control. There was appropriate personal protective equipment (PPE) available for staff to use when delivering personal care.

Medicines were not always safely managed. Medicine risk assessments were not person-centred. For example, 1 person’s medicine risk included generic information such as medicines should not be administered by untrained staff, incorrect recording of medicines missed medications, or theft of medication/abuse of medication. The information was not person-centred as it did not detail exactly what the risks were to the person as an individual in relation to the medicines they are currently taking and how these should be safely mitigated.

One person had PRN (as and when needed) medicines to manage their anxiety and incidents of concern. This person’s risk assessment stated, ‘Staff to offer PRN during early signs of agitation’. However, the person’s PRN protocol stated, ‘PRN to be taken as a last resort when other strategies have failed,’ this was contradictory information.

The PRN protocol also documented, ‘Staff to use a tailored risk management plan with proactive and reactive strategies’. However, these strategies were not documented within the protocol.

This meant that staff were not aware of clear strategies to use to calm the person before deciding whether to use PRN medicines.

Medicine Administration Records (MARs) were completed in full and were legible. We saw that there was an up-to-date medicines policy in place. Records showed that staff had received training on the administration of medicines and their competency to administer medicines had been assessed and medicines were safely stored.