We completed an inspection between 28 July 2025 and 05 August 2025. Q-Leaf Care Limited is a domiciliary care service providing the regulated activity of personal care to people in their own homes. Not all people received personal care at the time of the inspection. We have assessed 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. At the last inspection, the provider was not aware of the RSRCRC guidance. At this inspection the provider had not taken steps to address this and implement the guidance as it was not in place and the registered manager was not aware of the RSRCRC guidance. Whilst the registered manager was unaware of the guidance, they were able to demonstrate how they were supporting people to have to be independent and in control of their care and support as much as possible. The provider identified issues regarding the culture within the staff team, this included staff not always reporting incidents formally to the senior leaders. The registered manager was aware of this and taking action to support staff. The registered manager supported staff with supervisions and 1-1 meetings to give opportunities for staff to share concerns. People’s health risks were well managed, and staff completed training relevant to their role. People’s needs were fully assessed prior to their care and support being delivered. The provider worked well with other partners and health professionals to ensure people received joined up and coordinated care. The provider had governance processes in place to assess the service and make improvements where necessary. The provider was previously in breach of the legal regulation in relation to safe care and treatment, good governance and fit and proper persons employed. At this inspection, improvements were found in relation to fit and proper persons and the provider was no longer in breach of this legal regulation. However, not enough improvements had been made at this inspection in relation to safe care and treatment and good governance. Therefore, the provider remains in breach of the legal regulation in relation to safe care and treatment and good governance.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-13212876086.
Q Leaf Care Limited's first inspection rated the service Requires Improvement overall, with breaches of Regulations 12, 17 and 19 covering unsafe medicines management, ineffective governance and weak recruitment. Caring was rated Good, with very positive feedback from people and relatives, but training, supervision, complaints handling and learning from incidents need significant improvement.
Concerns (12)
criticalMedication management: “Medicines were not always managed safely and in line with national guidance. Medicine guidelines were not always followed.”
criticalMedication management: “staff who were supporting people with medicines had not all had competency checks completed to ensure they were able to administer medicines safely.”
criticalStaff training: “The provider's training matrix evidenced that staff supported people before completing mandatory training, including for example training to support people to transfer safely.”
criticalGovernance: “checks and audits ... failed to identify all the shortfalls highlighted within the inspection.”
criticalOther: “The provider had not ensured that all the information and safety checks required before new members of staff started work were in place.”
moderateIncident learning: “Accidents and incidents were not always used as an opportunity for learning. Incident forms did not always detail action taken to reduce further risks to people.”
moderateStaff competency: “Prior to our inspection not all staff supporting people had competency checks completed to check they knew how best to support people.”
moderateSupervision / appraisal: “the registered manager confirmed that they were in the process of supporting staff through formal supervisions, however not all staff had received supervision.”
moderateSafeguarding: “Staff had not all received training in safeguarding before working with people.”
moderateComplaints handling: “we identified all areas of the complaint had not been investigated and responded to by the registered manager.”
moderateRecord keeping: “there were entries written in pencil. There was no system in place to double sign written entries on MAR.”
minorEnd-of-life care: “people's end of life wishes and beliefs had not always been recorded.”
Strengths
· Consistent staff team delivering reliable, on-time care with very few missed visits
· Strongly positive feedback from people and relatives about kind, caring and respectful staff
· Person-centred care plans including 'Who I am' and 'What's important to me' sections
· Good infection prevention and control practices, with effective PPE use
· Positive culture and approachable management team
Quality-Statement breakdown (20)
safe: Using medicines safelyNot rated
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Supporting people to eat and drink enough to maintain a balanced diet
Not rated
effective: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Respecting and promoting people's privacy, dignity and independence; Supporting people to express their views and be involved in making decisions about their careNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering, which achieves good outcomes for peopleNot rated
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristics; Working in partnership with othersNot rated
well-led: How the provider understands and acts on the duty of candourNot rated