TerraBlu Homecare was rated Requires Improvement overall following a focused February 2022 inspection of safe and well-led, with five regulatory breaches identified spanning safeguarding, medicines management, risk assessment, recruitment, and governance. While people generally reported positive experiences of care, systemic failures in audit activity, CQC notifications, and staff training created significant safety risks.
Concerns (10)
critical
Safeguarding
: “Two people had reported to the registered manager that a staff member had stolen from them. The registered manager had not reported this to the local authority following the local authorities safeguarding protocols.”
criticalMedication management: “MAR records did not list which medicines staff were giving. One person's MAR showed that staff had been giving a different amount of medicines to what was listed on the MAR.”
criticalStaff training: “Training records evidenced that staff did not complete the provider's mandatory training before they commenced their shadowing shifts, induction and work.”
criticalStaff competency: “'A few times someone has come with no hoist (standing hoist) experience and I have had to talk them through this.'”
criticalGovernance: “Audits had not picked up shortfalls in practices in relation to risk assessment, safeguarding, medicines management, staff recruitment, training, care planning, recording and notifications.”
moderateCare planning: “Care plans and risk assessments were inconsistent and did not always detail the relevant information staff would need to meet people's assessed care and health needs.”
moderateIncident learning: “One person had fallen and injured themselves in January 2022 and had been found by a staff member. This had not been appropriately recorded.”
moderateRecord keeping: “Medicines records from December 2021 had been returned to the office for checking but had not yet been checked.”
moderatePerson-centred care: “Care plans for people with a learning disability and or autism were not structured to support people to achieve their goals and aspirations.”
minorCommunication with families: “'TerraBlu have been very stretched lately so the times of calls are all over the place. They always turn up but don't always let me know.'”
Strengths
· Most people and relatives gave positive feedback about care and support, describing staff as caring, well-trained and attentive to individual preferences.
· Staff understood how to recognise and report abuse and were confident in identifying safeguarding concerns.
· DBS criminal record checks and reference checks were completed for all staff.
· Infection prevention and control was well managed, with adequate PPE supply and relevant staff training.
· Complaints were investigated thoroughly, with management meeting people and relatives and providing written outcomes.
Quality-Statement breakdown (11)
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
TerraBlu Homecare received an overall rating of Good at its November 2017 inspection, with Effective rated Requires Improvement due to inconsistent care plan updates when needs changed, absent annual staff appraisals, and one lapsed medication training record. The service demonstrated particular strengths in safeguarding, medicines safety, recruitment rigour, infection control, and an open, inclusive organisational culture.
Concerns (5)
moderateCare planning: “People's needs and choices had been assessed when they started using the service, but changes to their needs had not consistently been identified or planned for.”
moderateRecord keeping: “The risk assessments we saw were not robust and merely described potential harm to people. There was no corresponding mitigation of the hazard via effective control measures.”
minorCare planning: “Care plans did not always fully reflect people's preferences. There was insufficient information recorded for staff to know how the person preferred to be supported, or their likes or dislikes.”
minorSupervision / appraisal: “Staff received supervision from their line manager but did not have annual appraisals to review their learning or reflect on their performance.”
minorStaff training: “We found one staff member whose medicines training had expired.”
Strengths
· People felt safe and staff were described as kind, compassionate and trustworthy.
· Robust recruitment procedures including DBS checks, reference verification and thorough induction with shadowing.
· Medicines management was safe, with blister packs, MAR chart auditing and quarterly competency spot checks.
· Effective safeguarding awareness: staff could identify abuse types and escalation routes confidently.
· Strong infection control practices including regular PPE spot checks and staff training.
Quality-Statement breakdown (22)
safe: Risk assessmentsRequires improvement
safe: SafeguardingGood
safe: Staffing levelsGood
safe: RecruitmentGood
safe: Medicines managementGood
safe: Infection controlGood
effective: Care planning and needs assessmentRequires improvement
TerraBlu Homecare received a Good rating across all five key questions at its announced inspection on 28 October 2015, demonstrating safe, personalised and well-managed domiciliary care for 69 people in the Tunbridge Wells and Tonbridge areas. No regulatory breaches were identified, and the service showed strong practices in safeguarding, medicines management, staff development, person-centred care planning, and quality assurance.
Strengths
· Staff trained in safeguarding, knowledgeable about recognising abuse signs and referral procedures
· Risk assessments centred on individual needs with clear staff guidance; accidents and incidents monitored for trends
· Sufficient staffing levels calculated according to people's changing needs; safe recruitment practices followed
· Medicines administered safely with quarterly competency checks, monthly audits, and re-training where shortfalls identified
· Comprehensive induction, annual essential training, and additional specialist training (diabetes, dementia, mental health)