Date of assessment: 7 to 9 January 2026 B24 Healthcare Solution Limited is a domiciliary care agency providing personal care to people in their own homes. At the time of our inspection the service provided packages of care to 85 people, of which 84 received the regulated activity of personal care. The service was registered to provide support to older people, younger adults, people living with a diagnosis of dementia, people with a learning disability and people on the autistic spectrum and people with a physical disability. At the time of our inspection, people in receipt of a service were older people and younger adults. No service was provided to anyone with a learning disability or persons on the autistic spectrum. The service was also registered to provide supported living. The service was not providing this support at the time of our inspection; therefore, we did not assess it. The last rating for this service was requires improvement (report published 16 January 2024). We identified 2 breaches of the regulations related to safe care and treatment and good governance. We requested an action plan from the provider to tell us how they intended to make the required improvements. We undertook this inspection to check they had followed their action plan. We found sufficient improvement had been made in safe care and treatment and the provider was no longer in breach. Whilst we found improvements in governance this was not sufficient, and we found the provider remained in breach of the legal regulation relating to good governance. This was the third consecutive inspection where the provider had not met this legal regulation. Staff carried out some checks on the quality and safety of the service. However, there was limited oversight from the provider to ensure checks drove effective improvements. Some checks did not identify the concerns we found during the inspection. Medicines were not always safely managed to ensure manufacturer’s directions were followed. Medicine administration records were in place, but other important records; body maps for the safe administration of transdermal (skin) patches were not. Staff received safeguarding training and understood their role in protecting people from abuse. Overall, the provider understood their role in making safeguarding referrals and working with other agencies. The provider had not, however, implemented their own policy related to staff handling people’s money. Care planning documentation was personalised and contained most of the information staff needed to care for and support people. Risk assessments were in place and most risk mitigation gave staff the details they needed to keep people safe from avoidable harm.
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B24 Healthcare Solution Limited was rated Requires Improvement across all five key questions following a December 2023 inspection, with breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) identified. Key failures included inaccurate and contradictory care records placing people at risk, ineffective governance and delegated audit oversight, inadequate staff training for specialist tasks, and lack of awareness of the Accessible Information Standard.
Concerns (12)
criticalCare planning: “Some people's care plan and risk management plans referred to other people (who used the service) within their care record.”
criticalRecord keeping: “Care records did not always contain accurate information. For example, one person's risk management listed they were diabetic. However, the person was not diabetic.”
criticalGovernance: “Delegated audits of medicine administration records had identified areas that required improvement... monthly audits continued to find the same areas and same staff.”
criticalSafeguarding: “The provider had acted outside of their service user bands and accepted a package of care to support a person with a learning disability... did not give staff training in learning disabilities.”
moderateStaff training: “Staff also undertook specific tasks, such as stoma care, which the provider had not given them training in or assessed staff competency in.”
moderateStaff competency: “Neither the registered manager or provider had a current recognised qualification in moving and handling to enable them to assess whether they were using safe practices.”
moderateCommunication with families: “The registered manager and provider were not aware of their responsibilities under the Accessible Information Standard.”
moderateComplaints handling: “One relative told us, 'Following a complaint, I requested the managers do not send a specific staff member to the care call, but they continue to do so.'”
moderatePerson-centred care: “The provider had directed care staff to 'toilet train' one older person living with dementia.”
moderateIncident learning: “The provider had handled 1 incident as a complaint and not identified the allegations as reportable.”
minorMedication management: “Some people were prescribed topical medicines such as creams. Whilst these were recorded on their MAR, there was no body map in place to direct staff where to apply creams.”
minorLeadership: “The provider had failed to display their rating from their last inspection on their website as required.”
Strengths
· Staff were recruited safely with pre-employment checks, DBS checks and right-to-work verification in place.
· People were protected from abuse; staff were trained in safeguarding and understood reporting responsibilities.
· Sufficient staff were available to cover care calls, with the registered manager and provider providing cover when needed.
· People and relatives generally gave positive feedback about care staff being kind and caring.
· The provider worked collaboratively with healthcare professionals including occupational therapists, district nurses and speech and language therapists.
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentGood
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
B24 Healthcare Solutions Limited, a domiciliary care agency supporting 28 older people, was rated Requires Improvement overall at its first inspection, with breaches of Regulation 17 (Good Governance) and Regulation 19 (Fit and Proper Persons Employed) identified. Whilst staff were described as caring and people's personal care was delivered with dignity, significant shortfalls were found in recruitment practices, staff training completion, mental capacity assessments, and the effectiveness of quality auditing systems.
Concerns (10)
criticalStaffing levels: “Staff were not always recruited in a safe way. We identified shortfalls in pre-employment checks undertaken by the registered manager.”
criticalRecord keeping: “Application forms had not always been fully completed by applicants. For example, there were gaps in employment histories that had not been addressed.”
criticalGovernance: “Systems had not been established to ensure effective quality checks were completed as required. This placed people at risk of harm. This was a breach of regulation 17.”
moderateStaff training: “One staff member had commenced employment during September 2022 but still had 8 training topics to complete. This included key training topics including infection control.”
moderateStaff competency: “Medicine competency assessments were not completed by the registered manager to assess staff's safe handling of medication.”
moderateConsent / capacity: “A person was living with dementia and experienced anxiety, confusion and memory loss...but had no mental capacity assessment in their care plan to guide staff around consent to care.”
moderateCare planning: “A person's care plan contained conflicting information for staff about how to assist a person with dementia with their medicines. This had not been identified by the registered manager.”
minorIncident learning: “Whilst the registered manager could tell us about actions that had been taken, they had not always recorded actions and outcomes on their incident report.”
minorEnd-of-life care: “Care plans around people's future wishes for their care, and where they wished to be cared for, had not been explored.”
minorCommunication with families: “One relative told us, 'We cannot always understand what the staff are saying due to their spoken English.'”
Strengths
· People and relatives gave positive feedback about staff being kind, polite and caring.
· There were sufficient staff to undertake agreed care calls and care calls took place at agreed times.
· People's independence was promoted; one relative noted mobility improvements since returning from hospital.
· Staff respected people's privacy and dignity during personal care, including gender preferences.
· Care plans were personalised and people were involved in agreeing their support.
Quality-Statement breakdown (20)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionRequires improvement
safe: Learning lessons when things go wrongRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Staff work with other agencies to provide consistent, effective, timely careRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Planning personalised care to ensure people have choice and controlGood
well-led: Managers being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; Working in partnership with othersGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff work with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportRequires improvement
well-led: Managers being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Continuous learning and improving care; Working in partnership with othersGood