Date of assessment: 29 October to 21 November 2025. Premier Care Limited Specialised Services was registered as a domiciliary care agency providing personal care to people in their own homes. The service was supporting 6 people with a regulated activity at the time of the assessment. The assessment was triggered by intelligence we received from the local authority. The local authority had been working with the provider and had agreed to a temporary suspension of new referrals since May 2025. The service has been rated inadequate. The provider was previously in breach of the legal regulation in relation to good governance. Improvements were not found in this assessment, and the provider was still in breach of this regulation. We identified 5 breaches of the legal regulations. The service was in breach for person centred care, need for consent, safe care and treatment, staffing, and good governance. We found significant shortfalls in how the service had been led. The provider had failed to maintain effective governance systems. Significant improvements were needed across the service. A new management team had started this work and improvements were being implemented. Senior staff still needed to be recruited, and any improvements also needed to be fully established and sustained. People’s care plans were not fit for purpose and needed updating to ensure they met people’s needs. This included the need for consent and documentation to support people who were not able to consent. Staff did not always assess risks to people's health and safety or mitigate them where identified. Safeguarding policies were not consistently followed. Staff did not always receive the level of training and support required to work safely. We identified health and safety shortfalls in relation to people’s homes. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-123167741.
Premier Care Limited – Specialised Services retains a 'Requires Improvement' overall rating, with a breach of Regulation 17 (Good Governance) due to risk assessments and support plans not being reviewed or updated following incidents. Strengths include kind and respectful care, safe medicines administration following recent improvements, and well-supported staff, but the absence of a registered manager and ineffective governance oversight remain key concerns.
Concerns (4)
criticalGovernance: “Systems and processes had not identified the lack of regular review to risk assessments and support plans. These had not been updated following any incidents or accidents.”
moderateCare planning: “Risk assessments had not been reviewed and revised following any incidents or accidents. We found no evidence of harm caused to people, but the lack of review increased the risk of reoccurrence.”
moderateLeadership: “There was no registered manager in post at the time of this inspection. The provider was committed to ensuring the right person was appointed to the position of registered manager.”
minorRecord keeping: “It wasn't clear if a morning call to someone needing personal care had been undertaken due to the method of logging in.”
Strengths
· People told us they felt safe and were treated with kindness, compassion and respect.
· Staff were enthusiastic about external mental health training including a 12-week course covering conditions such as OCD.
· Recent improvements had been made to medication administration processes; people now received medicines as prescribed.
· Safe recruitment practices were followed with all pre-employment checks including DBS completed before staff started.
· Staff supported people to maintain independence; one person no longer required personal care due to staff input.
Quality-Statement breakdown (23)
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: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
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
Premier Care Limited – Trafford & Manchester Mental Health Branch was rated Requires Improvement overall following a June 2016 inspection, with five regulatory breaches identified spanning safeguarding failures, unreported CQC notifications, inadequate staff training, absent care plan audits, and an outdated statement of purpose. Caring was rated Good, reflecting staff who routinely exceeded their contracted duties to support people's mental health and wellbeing.
Concerns (8)
criticalSafeguarding: “some of the incidents recorded in these logs had not been identified as safeguarding incidents and reported to the relevant authorities”
criticalIncident learning: “We had not received any notifications of any kind since November 2014... notifiable events were not being reported. This was a breach of Regulation 18”
criticalStaff training: “Nearly a third of staff were overdue refresher training. A course in recognising signs of mental distress had been discontinued... for two years”
criticalGovernance: “care plan audits... had not been done recently and the registered manager could not recall the last time it had been done... at least eighteen months”
moderateCare planning: “some files did not contain a great deal of personal information. When they did, some details were wrong. For example one person was recorded... as Church of England, but in fact... Roman Catholic”
moderateRecord keeping: “There was no date on it, so it was difficult to know when the next review was due... most recent one dated from October 2014 (20 months earlier)”
minorComplaints handling: “The complaints policy was out of date... dated 2010 and required updating”
minorPerson-centred care: “no practical work had been done with them to start the process... the service could play its part in moving away from a maintenance model”
Strengths
· Staff went beyond contracted duties, visiting hospitalised service users daily and providing carefully staged discharge transitions.
· Reliable medication ordering, storage, and weekly MAR sheet auditing systems were in place.
· 24-hour telephone access provided reassurance to people with mental health needs.
· Robust recruitment procedures including DBS checks and risk assessments for declared convictions.
· Regular two-monthly supervision with unannounced spot checks supported staff in their roles.
Quality-Statement breakdown (11)
safe: SafeguardingRequires improvement
safe: Medication managementGood
safe: Staffing and recruitmentGood
effective: Staff training and developmentRequires improvement
Premier Care Limited – Specialised Services was rated Requires Improvement overall at this January 2018 inspection, with a continuing breach of Regulation 17(1) for inadequate governance and quality assurance systems that failed to identify a medication administration error. While safeguarding, staff caring practices, and the open leadership culture were positive, weaknesses in medicines oversight, care plan quality, and inconsistent involvement of people in care reviews remained unresolved from the previous inspection.
Concerns (8)
criticalMedication management: “recording of one medicine not contained in the blister packs was inconsistent...we were not able to tell whether this medicine had been given correctly”
criticalGovernance: “Systems and processes to monitor and improve the quality and safety of the service were not adequate. This was a breach of Regulation 17(1)”
moderateRecord keeping: “none of the audit sections had been completed for either person's records we reviewed...audit tool was a simple check for the presence or absence of standard documents”
moderateCare planning: “one person's care plans had not been updated following a significant change in their care needs...information was not always clearly or consistently presented”
moderatePerson-centred care: “limited evidence of people, or others involved in their care were included in the development and review of their care plans...implemented inconsistently”
moderateStaff training: “up to 18 topics were covered over a three-day period during the induction...Seven of the 28 staff were overdue their refresher training by between one and four months”
moderateIncident learning: “medicines audit had not identified this shortfall...audit has also failed to recognise the gaps on this person's MARs as a potential issue”
minorComplaints handling: “The policy stated that all complaints should be acknowledged in writing within two days. We found this was not being done.”
Strengths
· Staff understood their responsibilities in relation to safeguarding and were aware of how to raise and escalate concerns
· Care was provided by small, consistent staff teams who understood people's needs and preferences
· Staff demonstrated understanding of the importance of supporting people to be independent and gain new skills
· Registered manager encouraged an open and honest culture within the service
· Staff supported people to access a range of health professionals and community activities
Quality-Statement breakdown (15)
safe: Medicines managementRequires improvement
safe: SafeguardingGood
safe: Risk assessment and managementGood
safe: Staffing levels and recruitmentRequires improvement
Premier Care Limited – Specialised Services was rated Good overall at its May 2019 inspection, having improved from Requires Improvement, with strong person-centred practice and partnership working evident across safe, effective, caring and responsive domains. Well-led was rated Requires Improvement due to reactive rather than proactive governance, gaps in medicines oversight, and an insufficiently developed care plan audit process.
Concerns (6)
moderateMedication management: “two occasions in February 2019 when there had been a delay in one person receiving their medicines (some of which it was important they received in a timely way)”
moderateGovernance: “provider's monitoring and quality assurance processes had not identified the issues we found relating to procedures around medicines management”
moderateGovernance: “last inspection we highlighted the lack of depth of the care plan audit. The audit had not improved, and the third-party auditor's report also highlighted the lack of a care plan audit”
minorRecord keeping: “written outcomes to complaints were not always provided or recorded within the complaints file”
minorCare planning: “staff had not given full consideration as to how they could meet recommendations made in relation to one person's health care needs”
minorRecord keeping: “did not clearly record post-incident observations for people in 24-hour care following potential head injuries”
Strengths
· People received support from consistent teams of staff who knew them and understood their needs and preferences.
· Staff supported people to take part in meaningful activities including exploring employment opportunities.
· People and relevant representatives were involved in planning and reviewing their care and goals.
· Service demonstrated learning from safeguarding investigations and participated in a safeguarding adults review.
· Positive feedback from social care professionals about partnership working and person-centred support.
Quality-Statement breakdown (21)
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: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
Premier Care Limited – Specialised Services was rated Requires Improvement overall following a focused inspection of safe and well-led domains, with breaches of Regulation 12 (safe care and treatment) due to insufficient risk assessment detail and Regulation 17 (good governance) due to a lack of robust quality assurance oversight. The service had declined from its previous Good rating, with longstanding governance issues unresolved since the 2019 inspection and a failure to notify the local authority of concerns about uncompleted care calls.
Concerns (8)
criticalCare planning: “risk assessments were of variable detail, with some containing very little information about how to support the person to manage and reduce the identified risk”
criticalGovernance: “lack of a robust, evidenced quality assurance system and the lack of recorded oversight by the provider was a breach of regulation 17”
criticalSafeguarding: “the local authority had not been informed about concerns that calls had been claimed as being completed when they hadn't been”
moderateIncident learning: “the same issues. Risk assessments and staff guidance were brief and did not provide sufficient information for staff to manage the known risks”
moderateSupervision / appraisal: “KPI record sheet showed a large number of staff spot checks, competency observations and supervisions had not been completed as scheduled”
moderateMedication management: “Premier Care systems were not being used to manage any changes in people's medicines and to record the action taken where issues were found with the MARs”
minorRecord keeping: “field managers completed spot checks, but these had not been logged in the quality assurance system”
minorPerson-centred care: “keyworker system had lapsed as staff had been re-allocated around the service and needed to be re-instated so people had more involvement in their support”
Strengths
· People received their medicines as prescribed and pharmacy-printed MARs were used to record all medicines administered.
· Staff were safely recruited with all pre-employment checks completed prior to starting work.
· The rostering system prevented one member of staff being allocated to two calls simultaneously, and staff logged in and out of each call via mobile phone.
· Staff were provided with PPE and followed current government COVID-19 guidelines.
· Staff reported feeling well supported by the management team with regular supervisions and team meetings.
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; supporting people to live healthier lives and access healthcareGood
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: Planning personalised care to ensure people have choice and control; supporting social and cultural participationGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles; understanding 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 staffGood
well-led: Working in partnership with othersGood
well-led: How the provider understands and acts on the duty of candourGood
responsive: Complaints handling
Requires improvement
well-led: Governance and quality assuranceRequires improvement
well-led: Notifications and regulatory complianceRequires improvement
caring: Person-centred and respectful care
Good
caring: Involvement in care decisionsGood
responsive: Care planning and reviewRequires improvement
responsive: Activity and community involvementGood