Date of assessment: 23 February to 30 March 2026. The service provides personal care support to adults and people with a learning disability in their own home. At the time of the assessment the service was supporting 34 people with a regulated activity. This assessment was carried out in response to the rating of requires improvement at the last assessment and due to safeguarding concerns, we received about the service. At the time of the assessment there were no people using the service who had a learning disability. As a result, we were not able to assess the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The service had still not fully implemented an effective system to manage the governance of the service, and we still identified some shortfalls. For example, we still saw some care plans and risk assessment had incomplete, inconsistence or missing information. This meant staff did not always have clear and accurate guidance to deliver safe and consistent care. Assessments of individuals’ needs were still not always reflected clearly or comprehensively in care plans. This meant care planning did not always provide a reliable picture of the support people required. Some documentation in relation to medicines was also still not completed comprehensively. This meant there was a risk that medicines may not always be managed safely. Safe recruitment practices had improved but were still not always being completed in line with the provider’s policy and legislation. This meant staff employed may not be suitable to work with vulnerable people. Mental Capacity Assessments (MCAs), required under the Mental Capacity Act 2005, were not being completed for people who may lack capacity. This meant decisions about their care may not have been made lawfully or in their best interests. We found no evidence that people had come to harm because of these shortfalls. However, new quality systems had been added since the last inspection to strengthen the oversight of risk and performance.We now saw recent audits had identified the need to further review assessments, care plans and risk assessments to ensure they were effective. A service improvement plan was in place, and the registered manager was progressing through the required actions. The provider was now notifying statutory agencies in line with their regulatory responsibilities. Staff told us they felt supported by the service’s leadership and demonstrated an understanding of their roles and responsibilities when supporting people with a range of needs. Staff had also received appropriate training for their roles. There was a shared vision and culture within the service, and leaders demonstrated openness, honesty and transparency. The service had made some improvements and were no longer in breach of safe care and treatment, failure to send notifications and staff being recruited safely. We identified one breach of the legal requirement in relation to governance. We have asked the provider for an action plan in response to the concerns found at this assessment.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-13166678180.
Vitality Plus Care Ltd was rated Requires Improvement overall at its first inspection, with four breaches of regulation covering unsafe recruitment, poor medicines management, inadequate risk assessment, and ineffective governance. While people spoke positively about caring staff, systemic failures in audit follow-through, care planning, and oversight created avoidable risks for the 42 people using the service.
Concerns (10)
criticalMedication management: “Medicine care plans for two people were incomplete or not started. This put people at risk of being administered the wrong medication.”
criticalStaffing levels: “Staff were not always recruited in line with safer recruitment practices. One person had started work before their DBS was received and without a risk assessment.”
criticalCare planning: “People did not always have care plans developed before support was provided, this meant they were at risk of receiving poor support.”
criticalGovernance: “The registered manager completed quality checks, audits, and supervisions but when issues were identified no actions were taken to address these.”
criticalLeadership: “The registered manager had not always sent appropriate notifications to the CQC. Failure to send notifications to the CQC is a breach of Regulation 18.”
moderateRecord keeping: “One person had been given information about another person in their care plan.”
moderateStaff training: “Several staff had not completed their refresher training for some of their training in line with company policy.”
moderateIncident learning: “The manager had recorded that one member of staff was wearing PPE incorrectly but there was no evidence that there had been an attempt to rectify this.”
moderateCommunication with families: “Because English was not always the first language of carers, there was at times a difficulty in accurate communication.”
moderatePerson-centred care: “Staff we spoke to could not tell us what person-centred care was, despite them having attended training.”
Strengths
· People using the service told us that they felt they were supported well and staff were 'very caring and delivered good care'.
· Staff had received safeguarding training and could explain what to do if they had concerns about someone at risk of abuse.
· People and relatives felt they were safe using the service.
· Staff were receiving regular supervisions and the manager was described as 'very approachable'.
· The provider had systems in place to effectively respond to concerns and complaints.
Quality-Statement breakdown (20)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infection, learning lessons when things go wrongRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced diet
Good
effective: Staff working with other agencies to provide consistent, effective, timely careGood
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
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: How the provider understands and acts on the duty of candourRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood