Date of assessment: 13 October 2025 to 27 October 2025. This responsive assessment was carried out to check if the service had made improvements since our last inspection. Operations office is a ‘supported living’ service and is registered to provide the regulated activity of personal care to people, primarily with learning disabilities living in their own homes. Not everyone using Operations Service received regulated activity; the 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 take into account any wider social care provided. This assessment was carried out with a site visit to the office location and the supported living service. This assessment was carried out by an inspector and a regulatory coordinator. We looked at 17 quality statements as part of this assessment. We gave the service 48 hours’ notice of the inspection. This was because we wanted to make sure someone would be available to support us with the inspection. We gathered further information remotely from the service such as training records and policies. We also spoke with relatives of people that used the service and staff after the site visits. We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
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First inspection of a small domiciliary care agency rated Requires Improvement overall, with concerns around expired manager training, lack of MCA consent assessments and absent audit/quality monitoring systems. Safe, caring and responsive domains were rated Good, with positive feedback on safeguarding, person-centred care plans and staff kindness.
Concerns (7)
moderateStaff training: “the registered manager who also supported people with personal care, most of their training had expired in 2020 and refresher training had not been undertaken”
moderateConsent / capacity: “Consent had not been sought from people for the service to provide care and support to them.”
moderateConsent / capacity: “For people that did not have capacity, assessments had not been carried out using the MCA principles to determine if people did not have capacity”
moderateGovernance: “Robust audit systems were not in place to ensure people received safe effective personalised care.”
moderateMedication management: “Audits had not been completed on medicines, which would make it difficult to identify potential shortfalls or errors with medicines.”
moderateStaff competency: “Spot checks had not been completed to ensure staff were competent to deliver good care.”
moderateGovernance: “There was not system in place for quality monitoring to ensure people, relative's or staff feedback could be sought and used to make improvement to the service.”
Strengths
· Risk assessments completed with control measures for specific health conditions and behaviours
· Medicines administered as prescribed with MAR charts and trained staff
· Robust pre-employment checks including DBS, references and right to work
· Staff trained in safeguarding and clear on how to report concerns
· Staff used PPE and had received infection control training
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
caring: Ensuring people are well treated and supported; 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
well-led: Managers and staff 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 staff; Continuous learning and improving careRequires improvement