Date of assessment: 2 October 2025 to 10 October 2025. The service provides care and support to adults living in their own home and were providing support to 14 people with the regulated activity of personal care. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. We undertook this assessment as the service was previously rated requires improvement, so we checked to see if improvements had been made. The service had improved. We found care plans were more detailed and person-centred and individual risks were identified, assessed and mitigated against. Although governance systems had improved, these had not picked up shortfalls in recruitment practices. These shortfalls had not impacted on people’s care. The registered manager took action straight away to improve recruitment processes and developed an action plan to ensure improvements were sustained. There were enough staff to meet people’s needs. Staff had received training and supervision to develop their skills and the registered manager carried out observations and checks of staff practice while delivering care to people in their own home to ensure safety and quality was maintained. Where people did not have a relative or friend who could support them to maintain their health and well-being, staff referred people to healthcare professionals if people needed this support and followed their guidance where relevant. Staff understood their role, and their responsibility to make sure people were safeguarded from abuse.
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Open Doors Healthcare Services Ltd received an overall rating of Requires Improvement at its first inspection, driven by gaps in risk assessments and care plans (notably for oxygen therapy and RIG tube use) and quality assurance systems failing to identify these shortfalls. The service demonstrated consistent strengths in caring, responsiveness, staffing, safeguarding and multi-agency working, with people and relatives providing overwhelmingly positive feedback.
Concerns (6)
criticalCare planning: “A person was receiving their nutrition and medicines through a RIG tube. There was no risk assessment or care plan in place to guide staff.”
moderateCare planning: “Some risks to people were not identified and assessed and care plans did not have all the information staff needed to manage risks safely.”
moderateCare planning: “Risks associated with the use of oxygen had not been considered as part of the provider's environmental risk assessment process.”
moderateGovernance: “Systems for identifying and managing risks were not fully embedded...quality assurance systems had not identified these shortfalls.”
minorRecord keeping: “When a best interest decision was made, the provider had involved relevant people and professionals but had not fully recorded the best interest decision.”
minorPerson-centred care: “Some care plans lacked personalised detail. For example, people's wishes for end of life care were not well recorded.”
Strengths
· People felt safe and spoke highly of staff, describing them as kind, caring and compassionate.
· Medicines were managed safely with clear PRN protocols and accurate administration records.
· Sufficient staffing levels with no missed calls and visits running on time.
· Holistic needs assessments including cultural, religious, physical and mental health needs.
· Staff received thorough induction, relevant training and specialist competency assessments.
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and management; Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongGood
safe: Preventing and controlling infectionGood
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 care; Supporting people to live healthier livesGood
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: End of life care and supportGood
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, understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires 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 staff; Working in partnership with othersGood