During an assessment under our new approach
Date of Assessment: 8 – 30 April 2026.
The service is a care at home service providing support to adults of all ages living with dementia, nursing needs, mental health conditions and physical disabilities. At the time of our inspection, 7 people were being supported with the regulated activity of personal care.
The provider was in breach of the legal regulations relating to staffing and good governance.
People were supported by staff who were not always trained or recruited safely. Whilst people provided positive feedback regarding the care given by staff, safe recruitment practices were not followed. The provider could not demonstrate all staff were suitable, skilled or adequately trained to carry out their roles. Additionally, the provider did not demonstrate an open and transparent approach during the assessment process. Information requested by the Care Quality Commission (CQC) regarding the people they supported, and the staff employed was not accurate. Whilst the registered manager acknowledged they had provided inaccurate information part way through the assessment; this lack of transparency may have placed people at risk of unsafe care had we not identified who they supported through the records we viewed.
Staffing contingency arrangements were insufficient to ensure people received support when their usual carer was unavailable. People sometimes received support from temporary carers employed by the service or relatives covered their care calls. Whilst this meant care provision was not always effective, the provider had managed the expectations of people and their relatives, and they had consented to this.
Minimal systems were in place to check the quality of the service so the provider could not be assured they were identifying concerns to be able to drive improvement.
People had assessments of their care needs, but these were inconsistent in their quality. Where they had been completed in full, they were thorough, holistic and person centred.
Care calls were not always on time, but sufficient time was allocated to meet people’s needs. Care provision was person centred and focused on meeting people’s care needs in the way they wanted. The provider was proactive in amending care packages if needed to meet people’s needs as they wanted.
People were supported by staff who respected their privacy and dignity and promoted their independence. Despite gaps in their training, staff were knowledgeable about people’s needs and spent time getting to know people to deliver person centred care.
Despite the initial lack of transparency, the registered manager was knowledgeable and passionate about the role they had and understood where there were shortfalls in care provision. They had developed an action plan to drive improvements, but this had not yet been implemented.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
We have asked the provider for an action plan in response to the concerns found at this assessment.