Date of Assessment: 16 July 2025 to 29 July 2025. The service is a domiciliary care agency (DCA) providing support to people in their own homes. Not everyone using the service received a regulated activity; CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. This was a planned inspection not based on risk. At the time of this assessment, 12 people were receiving personal care from the service. We found one breach of legal regulations in relation to the management of notifications of other incidents. We found the provider had not consistently submitted safeguarding and serious injury notifications, as legally required. Whilst we found no harm or increased risk to people being supported, the provider had not notified us of important events relating to safeguarding and serious injuries. The provider had a record of any accidents and incidents; however, we found initial medical advice was not always sought and staff team learning from these events was absent. This was discussed with the provider to address. The provider was supported by a team of dedicated staff who enjoyed their role, had strong values and promoted people’s right to privacy, choice and independence. Staff received training and regular supervision. Staff were complimentary about their managers and the service they delivered. People and their relatives were fully involved in the assessment process. This ensured that people’s individual abilities were encouraged to maintain independence. They described the staff as kind, considerate and empathic. We found there was a positive culture of kindness and respect embedded within the service. The provider continued to demonstrate genuine care for people using the service outside of scheduled visits. We have asked the provider for an action plan in response to the concerns found at this assessment.
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This focused inspection of Adelfi Care Services found the service had fully remediated the previous breach of Regulation 19 (safe recruitment), lifting the overall rating from Requires Improvement to Good. The Well-led domain was rated Outstanding, reflecting exceptional leadership, robust governance, a deeply person-centred culture, and innovative community engagement.
Strengths
· Safe recruitment practices fully implemented following previous breach of Regulation 19, with DBS checks, employment history gaps explored, and identity/health checks completed.
· Electronic rota and medicines administration systems introduced, enabling real-time monitoring of care visits and regular medication audits.
· Exceptional person-centred culture with staff going above and beyond, including community outings, hospital visits, and bespoke wellbeing initiatives for individuals.
· Outstanding governance with robust quarterly audits aligned to CQC KLOEs, live visit monitoring, and mock inspections planned.
· Strong staff retention achieved through NVQ support, counselling funding, car repair loans, and extended shadowing induction — no agency staff ever used.
Quality-Statement breakdown (10)
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringOutstanding
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsOutstanding
well-led: Continuous learning and improving careOutstanding
well-led: Engaging and involving people using the service, the public and staffOutstanding
Adelfi Care Services, a small domiciliary care agency in Cheltenham, received an overall rating of Requires Improvement at its first inspection, driven by a regulatory breach (Regulation 19) relating to unsafe staff recruitment practices including missing reference checks and unexplored employment history gaps. Care delivery across effectiveness, caring and responsiveness was consistently Good, with strong person-centred practice, positive feedback from people and relatives, and effective medicines and risk management.
Concerns (3)
criticalStaffing levels: “Reference checks from staff's previous social care employers were not always sought to gather assurances about staff conduct.”
moderateRecord keeping: “there were gaps in some applicants' employment histories Records did not show that the recruiting managers had explored all gaps”
moderateGovernance: “the registered manager had not identified through their own monitoring processes that they had not followed their policy and were not meeting the legal requirements.”
Strengths
· People and relatives praised the caring nature and consistency of staff, with people reporting feeling safe and supported.
· Effective induction programme including Care Certificate, tailored shadowing, and regular competency assessments.
· Person-centred care plans covering all areas of need with regular reviews and involvement of people and families.
· Strong communication systems including regular surveys, staff meetings, and live access to care notes for relatives.
· Positive partnership working with healthcare professionals, commissioners, and the Gloucestershire Care Providers Association.
Quality-Statement breakdown (22)
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Working in partnership with others, Continuous learning and improving careGood