AA-I-Care - 35 Southwell is a domiciliary care agency service providing personal care to people in their own homes. At the time of our inspection, they were providing a live-in care service with personal care to 6 people who lived in Dorset. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene. Where they do, we also consider any wider social care provided. The assessment took place between 30 September 2025 and 15 October 2025. We visited the location's office on 30 September 2025. We gave the service notice of the inspection. This was because it is a small service, and we needed to be sure that the provider would be in the office to support the inspection. During the inspection we assessed the quality statements under all key questions of safe, effective, caring, responsive and well led. We inspected this service partially to follow up shortfalls identified at the last inspection in August 2023, and partially because of concerns received about the quality and safety of the care provided. At our last inspection there were areas needing improvement, which included using medicines safely, assessing risk, staff recruitment, safety monitoring and management, and learning lessons when things go wrong. At the last inspection systems and processes were not in place to protect people from receiving unsafe care and treatment. Risks were not all appropriately assessed and mitigated. The competence and skills of staff to support people safely had not been assessed, and medicines were not managed safely. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found substantial improvements had been made in the management of risks, which were appropriately assessed and mitigated. Staff worked with people to assess any risks they faced. There were detailed risk management plans, which gave staff clear guidance on what to do to support people safely. People felt safe and staff were aware of their responsibility to identify and report potential abuse. Staff completed safeguarding training and were confident any concerns raised would be properly dealt with. There were enough staff to meet people’s needs, and people were supported by a consistent staff team. People were complimentary about the staff and positive relationships had been developed. People had a comprehensive care plan, which they helped devise and review regularly. There was an effective system in place to assess the competence of staff to give medicines and support people to move safely before they worked alone. Improvements had been made to the safe recruitment of staff. Staff had been recruited safely with all pre-employment checks completed prior to them starting. The provider had established a process of learning from events that had either put people and staff at risk of harm, or had caused them harm, to improve the service. Openness and transparency about safety was actively encouraged and embedded in the service. Enough improvement had been made at this inspection and, whilst some further work was needed to ensure the systems were embedded, the provider was no longer in breach of regulation 12.
PDF cached but not yet analysed by Claude — set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-137363385.
This targeted inspection of AA-I-Care - 35 Southwell found substantial improvements in risk management and medicines oversight since the previous Warning Notice, but a continued breach of Regulation 12 remains due to staff medicines competency assessments not being fully observed or embedded. The overall rating remains Requires Improvement; Regulation 19 breaches around recruitment were resolved.
Concerns (3)
criticalStaff competency — “4 of these staff had not been directly observed giving medicines as part of their recorded competency assessment. An additional member of staff had not had any competency assessments carried out and was lone working.”
moderateMedication management — “One person took their medicines with food and this was not referenced in their care plan. This meant staff did not have access to approved information about how to do this safely.”
minorCare planning — “The review and update of 1 person's risk assessment had not identified it continued to reflect out of date guidance about visitors to their home.”
Strengths
· Substantial improvements made in risk assessments and related care plans, including documentation of previously unrecorded health-related risk management plans.
· Improved oversight of medicines including auditing of prescriber's directions and timely addressing of discrepancies.
· MAR now provided to staff by the office with information to ensure people did not exceed maximum doses.
· People who received 'as and when required' medication had protocols in place to guide staff.
· Staffing and recruitment improvements sufficient to meet Regulation 19 — unexplained employment gaps explored and documented, and risk assessments carried out for staff with missing references.
Quality-Statement breakdown (4)
safe: Using medicines safelyInsufficient evidence to rate
safe: Assessing risk, safety monitoring and managementInsufficient evidence to rate
safe: Learning lessons when things go wrongInsufficient evidence to rate
safe: Staffing and recruitmentInsufficient evidence to rate
AA-I-Care - 35 Southwell was rated Requires Improvement overall following a May 2023 inspection, with breaches of regulations covering safe care and treatment (warning notice served), consent and mental capacity, governance, and fit and proper persons employed. Despite a supportive staff culture and positive feedback from people and relatives, critical failures in medicines management, MCA compliance, staff competency assessment, and oversight systems placed people at risk of harm.
Concerns (12)
criticalMedication management — “Discrepancies between the medicines administration records (MAR) and the instructions on the medicine for 3 people.”
criticalMedication management — “People who received 'as and when required' medication did not have guidance to support staff to administer these.”
criticalConsent / capacity — “Where a senior member of the team had determined the person could not consent to their care staff had signed consent on their behalf.”
criticalConsent / capacity — “Where care provided included restrictions...it was not clear that these decisions were made lawfully.”
criticalStaff competency — “Staff supporting people with their mobility had undertaken online training but had not had their practical competency assessed.”
criticalGovernance — “An allegation of abuse had not been shared and as a result it was not reflected on the safeguarding oversight tool...a statutory notification was not submitted to the CQC.”
criticalGovernance — “CQC had not been informed about a serious injury in 2022.”
criticalSafeguarding — “An allegation of abuse had not been shared and as a result it was not reflected on the safeguarding oversight tool.”
moderateRecord keeping — “Risks were not all appropriately assessed and mitigated...it was not possible to review the management of these risks because they were not recorded.”
moderateStaffing levels — “Recruitment processes were in place but these had not been operated effectively...unexplained gaps in all 4 recruitment records we reviewed.”
moderateIncident learning — “Systems to ensure appropriate actions following accidents and injuries had not been effective in ensuring appropriate notifications were made.”
minorCare planning — “People's oral care needs had not been clearly assessed and there was no information available in the care plan or handovers.”
Strengths
· People and relatives felt safe and expressed confidence in the kindness and compassion of staff.
· Staff had a good understanding of people's needs and encouraged them to make choices about their day-to-day lives.
· There was a supportive culture; staff felt looked after and would recommend the service as a place to work.
· The owner/provider was responsive to all issues raised during the inspection and committed to improvement.
· Good infection control practices noted by people and relatives: 'The hygiene standards are top notch.'
Quality-Statement breakdown (13)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
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: Staff support: induction, training, skills and experience