Blay Domiciliary Services is a domiciliary care agency providing personal care to people living in their own home. The assessment took place between 15 September and 9 October 2025. CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. Where they do, we consider any wider social care provided. At the time of this inspection, 239 people were receiving support with personal care. The service is registered for use by autistic people and people with a learning disability; therefore, the assessment took into account the principles of right support, right care, right culture. The service had made improvements. The provider had taken action to address the concerns identified at our last inspection in relation to safe care and treatment, mental capacity assessments and governance. The provider was no longer in breach of regulation. People were protected to keep safe. People were involved in the development and review of their care. Areas of risk on people’s lives were identified and support offered to mitigate these. The provider responded positively to feedback shared during the inspection. For example, the provider took actions to ensure consistent implementation of the principles of the mental capacity act in relation to capacity assessments. The provider also updated their service improvement plan to include the timescale for the roll out of improvement opportunities identified for care records. For example, to consistently provide detailed guidance for the administration of as required medicines. Staff received the appropriate training to their role and understood the principles of person-centred care and implemented these effectively. The provider implemented effective systems to ensure leaders had oversight of the service. Opportunities for improvement were identified and action taken to promote best outcomes for people.
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Blay Domiciliary Services was rated Requires Improvement overall following a focused inspection in December 2023, with regulatory breaches identified in safe care and treatment (Regulation 12, resulting in a Warning Notice), consent and mental capacity (Regulation 11), and governance (Regulation 17). Key failures centred on inadequate risk assessments, unsafe medicines management, non-compliance with the Mental Capacity Act 2005, and ineffective governance audits failing to identify or address these shortfalls.
Concerns (7)
criticalMedication management: “Staff did not always record administration of medicines properly...we saw gaps in people's medicine administration records (MARs).”
criticalCare planning: “1 person lived with a complex condition...The risk assessments and care plan for this person were contradictory and did not provide staff with clear guidance.”
criticalConsent / capacity: “People had no mental capacity assessments or best interest decisions completed...Key requirements of the Mental Capacity Act 2005 were not fully understood by staff.”
criticalGovernance: “Audits of people's care plans did not identify that they were not always comprehensive or up to date...risks were not always identified or managed appropriately.”
moderateRecord keeping: “Provider's systems did not identify all shortfalls in recording of people's care...staff did not always record their interactions and support for the person correctly.”
moderateStaff training: “"Training is not really sufficient. Not compared to the past. Some are more able than others...They're nice [carers] who would make good carers with more training."”
minorCommunication with families: “People and their relatives gave us mixed feedback about communication with the management team...others told us that it needed improvement.”
Strengths
· Robust recruitment systems ensuring right staff were recruited to support people to stay safe.
· Staff completed safeguarding training and had good understanding of abuse and reporting procedures.
· Effective incident recording, investigation and trend analysis to ensure lessons were learnt.
· Staff worked collaboratively with external health professionals including GPs, social workers and pharmacists.
· Infection prevention and control policy in place with all staff trained and supplied with appropriate PPE.
Quality-Statement breakdown (15)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: 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: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Supporting people to live healthier lives, access healthcare services and supportRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
well-led: Managers and staff being clear about their roles, 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 staffRequires improvement
Blay Domiciliary Services improved its overall rating to Good following a focused inspection of safe, effective and well-led, resolving previous breaches of Regulations 11 and 18. The effective domain remains Requires Improvement due to mental capacity assessments not yet being fully decision-specific, though sufficient progress was made to exit regulatory breach.
Concerns (1)
moderateConsent / capacity: “People's mental capacity had been considered but further work was needed to ensure capacity assessments were decision specific.”
Strengths
· Medicines were administered by trained staff with assessed competency; recent medicines audits completed to identify and reduce errors.
· Safeguarding training in place; staff knowledgeable on identifying abuse and reporting concerns, including whistleblowing.
· Pre-employment checks including references and criminal records checks completed before staff worked with people.
· Statutory notifications now submitted correctly following previous breach of Regulation 18.
· Quality monitoring through audits (medicines, complaints, training, IPC) used to drive improvement.
Quality-Statement breakdown (13)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidance (MCA)Requires improvement
effective: Assessing people's needs and choices; delivering care in line with standardsGood