Honeydew Healthcare Limited is a homecare agency providing the regulated activity personal care to people living with dementia, mental health conditions, people with physical disabilities, people over 65 years of age and people under 65 years of age. At the time of our assessment there were 5 people receiving a regulated service. We visited the service on 20 October 2025. The inspection was carried out because of the length of time since the last assessment. The assessment was a fully comprehensive inspection, which looked at key areas which included infection prevention control, medicines management, staffing, choice and control, governance, management, leadership and safeguarding people. During the last inspection we found the service was in breach of regulation 12 regarding assessing, monitoring and mitigating risks to the health safety and welfare of people using the service, regulation 17 regarding systems to monitor people were receiving safe and effective care in line with their needs and a breach of regulation 19 regarding safe recruitment of staff. During this inspection we found improvements in all these areas had been made and the service was no longer in breach of regulations. The provider demonstrated exceptional practice in ensuring people were put first. The provider had embedded a strong, proactive safety culture that prioritised openness, transparency and continuous learning. Staff consistently demonstrated an advanced understanding of risk management, enabling people to take positive risks while remaining safe. People were fully involved in decisions about their safety, and care plans contained detailed, dynamic risk assessments tailored to individual needs. Leaders worked collaboratively with healthcare professionals and families to develop seizure-safe travel plans which included specialist training and emergency protocols. This approach empowered people to maintain independence and control over their lives. Environmental safety was embedded into everyday practice. Staff were trained to identify hazards and escalate concerns promptly, supported by regular competency checks and scenario-based learning. Proactive referrals ensured homes were adapted to meet changing needs, enabling people to feel safe and respected in their own environment. Staffing was consistently safe and effective. There were always enough qualified, skilled and experienced staff to meet people’s needs, and continuity of care was maintained even during sickness. Recruitment processes were effective, and training was embedded into practice through competency observations and team meetings. The provider demonstrated strong lessons learned from incidents and shared these through ‘key points’ documents and additional training to ensure continuous improvement. People told us they felt safe, and they trusted staff, and relatives confirmed the service was highly responsive and inclusive. This distinctive, person-centred approach to safety, combined with strong governance and a culture of learning, meant people consistently experienced care that was not only safe but empowering and enabling.
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Honeydew Healthcare Ltd received an overall rating of Requires Improvement on its first CQC inspection, with regulatory breaches identified in safe care and treatment (Reg 12), governance (Reg 17), and fit and proper persons employed (Reg 19). While staff were praised for their kindness and caring culture, significant shortfalls in medicine management, care planning, staff competency for complex needs, and recruitment record-keeping placed people at risk of harm.
Concerns (10)
criticalMedication management: “Medicines which were 'as required' lacked clear guidance to ensure consistent administration. One person...had staff who were not familiar with how to administer their emergency medicine safely.”
criticalCare planning: “Care plans lacked details and guidance for staff in some areas to ensure consistent care...a lack of explicit step by step instructions for how to support people with their health conditions.”
criticalStaff competency: “People with more complex needs did not always have staff who understood their needs or have adequate training.”
criticalGovernance: “Quality assurance systems were not in place and embedded into practice to ensure people were receiving safe and high-quality care.”
criticalRecord keeping: “No start dates could be provided for staff files we checked. Therefore, it could not be determined who had criminal record checks and references prior to starting work.”
criticalSafeguarding: “Recruitment systems were not in line with current legislation or the provider's policy to keep people safe from inappropriate staff working with them.”
moderateStaff training: “The registered manager and senior staff were assessing competency around medicine administration...They had not completed higher level training to ensure they were following current best practice.”
moderateConsent / capacity: “Examples were seen when people's health had declined, and no capacity assessments or best interest decisions had been completed for any decisions.”
moderateEnd-of-life care: “People had not had their end of life plans considered other than legal requirements completed by health professionals.”
minorIncident learning: “The registered manager showed us the system they were developing to demonstrate they were learning when things went wrong.”
Strengths
· Staff were described as kind, caring and friendly; compliments praised the registered manager and team for compassion, kindness and sensitivity.
· People were supported by enough staff to meet their needs and staff preferences were considered.
· The registered manager was proactive, met new people prior to starting care and maintained regular contact with people and relatives.
· The service worked well in partnership with other health and social care professionals.
· People were supported to maintain independence and access the community; cultural and religious preferences were respected.
Quality-Statement breakdown (23)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongRequires improvement
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 law
Requires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
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 supportRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Promoting a positive culture; continuous learning and improving careRequires 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 staffGood